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10410223-DS-14 | 10,410,223 | 22,978,234 | DS | 14 | 2125-10-28 00:00:00 | 2125-10-28 15:21:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
confusion and difficulty with speech
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is an ___ year-old L-handed F w/ PMH of Alzheimer's
Dementia and cervical spondylosis who presents with aphasia and
confusion. Pt is unable to provide any history due to her
language deficits. Hx predominantly obtained from chart and son
over phone.
Per son, pt was in USOH until ___ afternoon when he stopped
by
her SNF and saw that pt seemed to be having worsening word
finding difficulties from her baseline and engaging in some odd
behaviors (pt taking pants and underwear off without clear
reason). Her family next saw her ___ night at dinner at which
time pt had "difficulty putting words together" and "words were
popping out of her mouth". Her son thought that maybe she was
simply having some functional waning in set of her dementia and
pursued no evaluation. The following day, his brohter tried to
speak to pt regarding some money issues and noted that she was
clearly incoherent and less interactive than normal. Today, pt's
SNF (___) called son out of concern that pt couldn't
speak and planned to send to ED for evaluation. While in ED, pt
noted to have +UA and treated empirically with Ceftriaxone.
NCHCT
was performed which showed new L frontal IPH. They reported
that
pt had nausea and constipation. As a result, pt was brought to
ED
for evaluation.
At bedside, pt is unable to provide history, only able to say
one
to two word phrases, but clearly endorsed pain in her L foot as
well headache over her vertex (unable/unwilling to provide
further details). Since onset of her sx, son denies any apparent
weakness, endorsed sensory deficits, or gait issues. He was not
aware of any facial droop but stated that the nursing home had
made some mention of facial asymmetry.
Of note, pt was evaluated at ___ in ___ for transient RUE
weakness. At that time, she was admitted for treatment of UTI.
Neuro evaluated pt with concern for TIA and recommended starting
ASA and statin therapy. Of note, on last neurologic evaluation,
pt's speech was fluent but unable to name low frequency objects,
repetition intact. Occasional hesitancies in speech.
Per son, at baseline she has moderate AD (dx ___. Able to live
in SNF with intact ADLs. She does have some intermittent WFD but
able to converse relatively well. Generally socially interactive
(comes to son's home for dinner).
Past Medical History:
Alzheimers Dementia
RA
Cervical Spondylosis/Degenerative disc disease in cervical spine
Osteopenia/osteoporosis
Rosacea
Bilateral cataract surgery
UTI
Social History:
___
Family History:
Alzheimer's disease in father. No history of CAD, stroke in
family to her knowledge
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
=====================================================
Vitals: T: 98.9 HR: 65 BP: 172/75 RR: 20 SaO2: 97% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, at least oriented to self.
Nonfluent speech w/ occasional ___ word phrases, poor repetition
and naming. Intermittent comprehension to questions and
commands.
Unable to sing "Happy Birthday". No clear alexia. Attentive to
examiner. No notable dysarthria. No evidence of hemineglect. No
left-right confusion. Able to follow some midline and
appendicular commands.
- Cranial Nerves: PERRL 1.5->1 brisk. VF full to threat. EOMI,
no
nystagmus. V1-V3 without deficits to light touch bilaterally. R
NLFF. Hearing intact to finger rub bilaterally. Pt
unwilling/unable to lift palate or shrug shoulders. Tongue
midline.
- Motor: Normal bulk, paratonia in UEs. No tremor or asterixis.
Unable to participate in formalized confrontational testing but
___ in all extremities b/l.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 1 1 1 0
R 2+ 1 1 trace 0
Plantar response WD bilaterally
- Sensory: No deficits to light touch, pin, or vibration
bilaterally (pt saying yes/no or "same").
- Coordination/Gait: Deferred
DISCHARGE PHYSICAL EXAMINATION
=
=
=
=
=
=
=
=
=
================================================================
Vitals: Temp: 98.1 BP: 114/61 HR: 58 RR: 19 O2 sat: 97% O2
delivery: RA
General: awake, alert, somewhat cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: RRR, skin warm, well-perfused
Abdomen: soft, nontender and nondistended
Extremities: symmetric, warm, distal pulses palpable, no edema
Skin: no rashes or lesions noted
Neurologic:
Mental Status: Alert, oriented only to self (states she is
teaching in school and year is ___. States she is here
"because
someone told me to." Inattentive and unable to list MoYB.
Hesitant and slow speech but language is fluent. Intermittent
comprehension to questions and commands. Poor repetition and
naming. Able to read out loud. No dysarthria noted. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or hemineglect. Confuses R and L. MOCA score
___. Profound short term memory impairment but able to recall
long term memories such as what she used to do for work.
Cranial Nerves:
II, III, IV, VI: 1mm surgical and nonreactive pupils b/l. EOMI.
VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: Able to shrug shoulders bilaterally.
XII: Tongue protrudes in midline.
Motor: Normal bulk, paratonia in UEs. No adventitious movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE IP Quad Ham TA Gastroc
L 5 5 4+ 5 4 5 5 5 5
R 5 5 4+ 5 4 5 5 5 5
Sensory: No deficits to light touch throughout. No extinction to
DSS.
DTRs:
Bi Tri ___ Pat
L 2 1 1 1
R 2 1 1 1
Plantar response WD bilaterally.
Coordination: Deferred.
Gait: Deferred
Pertinent Results:
ADMISSION LABS
====================================
___ 11:20AM BLOOD WBC-9.2 RBC-3.60* Hgb-11.8 Hct-35.5
MCV-99* MCH-32.8* MCHC-33.2 RDW-13.0 RDWSD-46.4* Plt ___
___ 11:20AM BLOOD Neuts-79.2* Lymphs-11.7* Monos-7.9
Eos-0.4* Baso-0.4 Im ___ AbsNeut-7.28* AbsLymp-1.08*
AbsMono-0.73 AbsEos-0.04 AbsBaso-0.04
___ 11:20AM BLOOD ___ PTT-26.8 ___
___ 11:20AM BLOOD Glucose-110* UreaN-14 Creat-0.7 Na-132*
K-4.3 Cl-96 HCO3-24 AnGap-12
___ 11:20AM BLOOD estGFR-Using this
___ 11:20AM BLOOD ALT-33 AST-44* AlkPhos-232* TotBili-0.6
___ 05:30AM BLOOD ALT-30 AST-40 LD(LDH)-304* CK(CPK)-442*
AlkPhos-220* TotBili-0.7
___ 11:20AM BLOOD Lipase-32
___ 11:20AM BLOOD cTropnT-0.05*
___ 11:20AM BLOOD Albumin-3.6
___ 05:30AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.5 Mg-1.9
Cholest-167
___ 05:30AM BLOOD %HbA1c-5.3 eAG-105
___ 05:30AM BLOOD Triglyc-82 HDL-78 CHOL/HD-2.1 LDLcalc-73
___ 05:30AM BLOOD TSH-3.1
___ 05:30AM BLOOD CRP-12.6*
___ 11:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:04PM BLOOD Lactate-1.4
==============================================
DISCHARGE LABS
==============================================
___ 05:10AM BLOOD WBC-8.6 RBC-3.52* Hgb-11.6 Hct-34.5
MCV-98 MCH-33.0* MCHC-33.6 RDW-13.2 RDWSD-46.6* Plt ___
___ 05:10AM BLOOD Plt ___
___ 05:10AM BLOOD Glucose-90 UreaN-15 Creat-0.6 Na-135
K-4.4 Cl-101 HCO3-24 AnGap-10
___ 05:10AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0
================================================
URINE
================================================
___ 12:53PM URINE Color-Straw Appear-Hazy* Sp ___
___ 12:53PM URINE Blood-TR* Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG*
___ 12:53PM URINE RBC-3* WBC->182* Bacteri-FEW* Yeast-NONE
Epi-0
___ 12:53PM URINE WBC Clm-MOD*
=================================================
MICROBIOLOGY
==================================================
___ 12:53 pm URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
=============================================
IMAGING
=============================================
___
1. Acute left frontal operculum hemorrhage with adjacent
vasogenic edema. No evidence of significant midline shift.
2. Small left frontal subarachnoid hemorrhage.
3. No evidence of underlying fracture.
___ H&N
Shows hemorrhage as noted above. Some levels of calcifications
present in anterior circulation, most notably in cavernous
portions of ICA.
___ MRI/MRA BRAIN
1. Left frontal operculum hemorrhage appears fairly similar
compared to prior imaging.
2. Mild linear enhancement in relation to the inferior central
aspect of the hemorrhage as well as superior to it suggest
breakdown of the blood-brain barrier.
3. No active extravasation was noted on the prior CTA done ___ and there is no flow related enhancement on the MRA.
4. No underlying mass or vascular malformation, but imaging post
resolution is advised to exclude underlying abnormality.
5. There is a small component of subarachnoid hemorrhage
overlying the cerebral hemispheres.
6. Note is made of superficial/cortical siderosis noted on the
prior study suggesting recurrent hemorrhage.
7. The intracranial arteries are patent without marked stenosis,
occlusion or aneurysm formation.
8. There is a small 2 mm bulge/infundibulum in the distal right
ICA proximal to the origin of the posterior communicating artery
which was better seen on prior CTA done ___.
9. Additional findings as described above.
Brief Hospital Course:
Ms. ___ is an ___ female with Alzheimer's dementia
and cervical spondylosis who presented with new difficulty with
speech from baseline found to have left frontal IPH and UTI.
Most likely etiology for her acute mental status decline is
cerebral amyloid angiopathy related IPH and UTI-related delirium
superimposed on her underlying dementia.
#ICH
NCHCT demonstrated left frontal IPH with surrounding edema.
Antiplatelet therapy and NSAIDs were held in setting of
bleeding. Her BPs were controlled with hydralazine prn with SBP
goal <150.
#DELIRIUM
Pt was oriented only to herself and was inattentive throughout
her hospitalization. Likely cause of her delirium is cerebral
amyloid angiopathy related IPH and UTI-related delirium
superimposed on her underlying Alzheimer's dementia.
#DEMENTIA
Consistent with her AD, pt was noted to have poor orientation
and attention. Home donepezil 5mg PO daily was continued during
hospitalization.
#UTI
+UA on admission and UCx showed E. coli. Treated with
ceftriaxone (___).
Transitional Issues:
-ASA held during this admission, please, restart do not restart
until indicated for cardiovascular risk factors.
-Follow up with neurology
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 5 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Psyllium Wafer 1 WAF PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Donepezil 5 mg PO QHS
3. Psyllium Wafer 1 WAF PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___
Discharge Diagnosis:
Left frontal intraparenchymal hemorrhagic stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were diagnosed with an ACUTE HEMORRHAGIC STROKE, a condition
from bleeding into the brain. The brain is the part of your body
that controls and directs all the other parts of your body, so
damage to the brain from being deprived of its blood supply or
bleeding can result in a variety of symptoms. Stroke can have
many different causes, so we assessed you for medical conditions
that might raise your risk of having stroke. In order to prevent
future strokes, we plan to modify those risk factors. Your risk
factors are:
[] cerebral amyloid angiopathy
We are changing your medications as follows: Please take your
other medications as prescribed. Please follow up with Neurology
as listed below. Please follow up with your regular doctor
within 14 days of discharge. If you experience any of the
symptoms below, please seek emergency medical attention by
calling Emergency Medical Services (dialing 911). In particular,
since stroke can recur, please pay attention to the sudden onset
and persistence of these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10410237-DS-16 | 10,410,237 | 24,906,931 | DS | 16 | 2148-09-11 00:00:00 | 2148-09-11 17:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Intractable nausea and vomiting.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o non-specific gait disorder, remote polysubstance
abuse (cocaine, heroin), chronic back/abd/leg pain, GERD
presents with N/V and diarrhea x 3 days. She was in her USOH
until ___ when she had the acute onset of N/V - 'every 5
minutes' - last episode was this AM (no bile, no blood) and
diarrhea ___ times per day, watery, no blood) - last episode
also this AM. She has not been able to eat or drink normally
since ___. She does also report intermittent upper abd pain,
which she attributes to vomiting. She came to the ED yesterday
for evaluation - had normal labs, CT, which showed
'irregular-appearing collapsed distal/terminal ileum may relate
to collapsed state', otherwise nl. She was given zofran and
morphine and discharged home. She returned to the ED today for
persistent N/V/D.
.
In the ED, initial VS 99.8 70 94/54 18 98% on RA. She was
given 2L NS, zofran, and morphine. Labs were remarkable for
lipase of 139, nl lytes/LFTs/CBC. EKG showed SR, LVH, and subtle
STD in inferior leads and subtle elevations in V1/V2 -
depressions more pronounced than on EKG from ___ but similar to
those yesterday in ED.
.
Currently, the patient is ambulating about the room and talking
on her cell phone. She tells me she has the 'noroflu' and that
her daughter and grandchild had it recently and now she thinks
her son has it as well. Her last episodes of diarrhea and
vomiting were this AM. No uncooked food. She c/o bil upper abd
pain - intermittent. She has had subjective fevers/chills, no
blood in stool and does describe SSCP, which she attributes to
frequent vomiting.
.
ROS: per HPI, denies night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Chronic abd/back/leg pain
Gastritis/duodenitis
GERD
Non-specific gait d/o
History of Polysubstance abuse (cocaine, heroin)
Hirsutism
h/o ectopic pregnancy
Uterine fibroids
Social History:
___
Family History:
Father died of pneumoconiosis and mother died of heart attack at
age ___.
Physical Exam:
On admission:
VS - 99.8 70 94/54 18 98% on RA
GENERAL - walking about the room, NAD
HEENT - NC/AT, PERRLA - L eye with subconjunctival hemorrhage,
EOMI, sclerae anicteric, MMM - dentures in place
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, unlabored
HEART - RRR, soft systolic murmur at LUSB, nl S1-S2
ABDOMEN - normoactive bs, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, shuffling gait
At discharge:
V/S afeb 60 110/60 100% on RA
Gen: appears well in NAD
HEENT: sclera anicteric, MMM
Neck: supple
CV: RRR, no m/r/g
Lungs: CTAB
Abd: +BS, soft, NT, ND, no HSM
Ext: wwp, no ___ edema
Pertinent Results:
On admission:
___ 10:40AM BLOOD WBC-10.7 RBC-4.26 Hgb-14.5 Hct-41.4
MCV-97 MCH-34.1* MCHC-35.1* RDW-14.1 Plt ___
___ 10:40AM BLOOD Glucose-104* UreaN-13 Creat-0.7 Na-142
K-4.0 Cl-104 HCO3-22 AnGap-20
___ 10:40AM BLOOD ALT-20 AST-31 AlkPhos-62 TotBili-0.4
___ 02:25PM BLOOD Lipase-139*
___ 10:40AM BLOOD cTropnT-<0.01
___ 02:25PM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:35PM BLOOD cTropnT-<0.01
___ 02:25PM BLOOD Albumin-3.8 Calcium-8.3* Phos-2.7 Mg-1.8
Labs prior to discharge:
___ 05:15AM BLOOD WBC-5.5 RBC-3.73* Hgb-12.1 Hct-36.0
MCV-97 MCH-32.4* MCHC-33.5 RDW-14.0 Plt ___
___ 05:30AM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-138
K-4.1 Cl-104 HCO3-25 AnGap-13
___ 06:50AM BLOOD Lipase-104*
___ 05:30AM BLOOD Calcium-8.7 Phos-4.3 Mg-1.9
Micro:
ESCHERICHIA COLI.
>100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
REPORTS:
___ CT abd/pelvis: 1. No acute abdominal or pelvic process.
2. Irregular-appearing collapsed distal/terminal ileum may
relate to
collapsed state. Suggest correlation with history of
inflammatory bowel
disease. 3. No CT evidence of acute pancreatitis, however
correlate with serum lipase, which is more sensitive.
___: 1. Pancreatic ductal dilation, with tapering in the
region of the pancreatic head, a finding that is similar in
comparison with prior CTs dating to ___, allowing for
differences in technique. Further evaluation could be obtained
with MRCP if clinically indicated. No evidence of peripancreatic
fluid collections to suggest acute pancreatitis, although a
normal ultrasound does not exclude the diagnosis of
pancreatitis. 2. Multiple echogenic liver lesions consistent
with hemangiomas, not significantly changed.
Brief Hospital Course:
___ yo female with h/o non-specific gait disorder, remote
polysubstance abuse (cocaine, heroin), chronic back/abd/leg
pain, and GERD presents with N/V and diarrhea x 3 days.
.
# N/V/D: Thought to be resolving gastroenteritis. CT findings on
initial presentation were non-specific. EGD in ___ showed
duodenitis/gastritis, so omeprazole was started. This
admission, lipase was mildly elevated likely in setting of
inflammation and vomiting. Also in differential was narcotics
withdrawal. She was started on IVF, antiemetics and pain
control.
.
# E.coli UTI: Ceftriaxone was started initially and was
transitioned to PO ciprofloxacin once sensitivities returned for
a course of three days.
.
# HTN: Patient was hypertensive to 150s/100s in-house and
intermittently as outpatient. This resolved, and further follow
up was deferred to outpatient management.
.
# Chronic pain: IV morphine was used initially, which was
transitioned to patient's home regimen of PO percocet.
.
Transitional issues:
*) CODE STATUS: Full Code
*) CONTACT: ___ ___
Medications on Admission:
Wellbutrin listed in OMR but hasn't been taking this
Percocet - mentions that 70 pills typically last her a month
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
2. Percocet ___ mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Please take last dose tonight.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Urinary Tract Infection
Nausea and vomiting
Abdominal pain
Secondary:
Chronic pain
h/o polysubstance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for nausea and vomiting. We
treated you with IV fluid, anti-nausea and pain medicine, and we
slowly advanced your diet and you improved.
We made the following changes to your medications:
START omeprazole to try to relieve your stomach pain and
irritation
START ciprofloxacin for urinary tract infection
Your follow-up information is listed below.
Followup Instructions:
___
|
10410641-DS-20 | 10,410,641 | 28,685,994 | DS | 20 | 2165-02-07 00:00:00 | 2165-02-10 23:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Shellfish Derived
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
___ y/o F with h/o Stage II pancreatic cancer diagnosed in ___ s/p pancreatoduodemectomy and adjuvant radiation and
Gemcitabine in ___, with new lung nodules seen in ___ and
development of ascites in ___, but without proven metastasis
or treatment since, now presenting with fever. Pt reports fever
to 102 at home accompanied by chills and rigors that started
this am. She also complains of increasing SOB over the past 2
weeks, with DOE, palpitations with exertion and increasing dry
cough. She denies any sputum production or fevers prior to
today. She also denies abd pain, increased abd girdth, nausea,
vomiting, dysuria but reports decreased UOP. She has stable
chronic diarrhea whic is unchanged.
Pt had been diagnosed with portal vein thormbosis in and has had
ascites since, no evidence of metastasis. She has been having
intermittent paracentesis, last a bout 3 weeks ago and on
lasix/spirinolactone.
In ED, pt's vital signs BP 99/56, HR 82, AF, O 90% on RA, 96% on
2LNC. She was treated empirically with Ceftriaxone for possible
SBP and had diagnostic paracentesis, which now shows WBC 168,
with 8% neutrophils, not c/w SBP. She also had a CXR which
shows a new large L pleural effusion and pt with new oxygen
requirement.
Full ten point ROS positive for weight loss over last few
months; otherwise negative except as noted.
Past Medical History:
* Infectious IBS
* Diabetes mellitus II - on oral hypoglycemics
* Pancreatic insufficiency - on pancreatic enzyme replacement
* T2, N1, stage IIB pancreatic adenocarcinoma as below
* Portal vein thrombosis
.
ONCOLOGIC HISTORY: ___ presented in ___ with 29
pound weight loss and was referred for endoscopic evaluation.
ERCP identified a stricture in the common bile duct and a stent
was placed. Subsequent studies, including MRCP identified a
mass
in the pancreatic head. On ___, she underwent
pylorus-preserving pancreaticoduodenectomy without complication.
Pathology revealed a T2 grade I adenocarcinoma. Three of ten
lymph nodes were involved. Margins were negative.
Lymphovascular invasion was indeterminate, and perineural
invasion was absent. She was diagnosed with T2, N1, stage IIB
pancreatic adenocarcinoma. Also noted in the pathologic
specimen
was pancreatic intraepithelial neoplasia and evidence of acute
on
chronic pancreatitis. Her preoperative CA ___ on ___
was
17 ng/mL. She began adjuvant gemcitabine on ___. The
gemcitabine was dose reduced with the third treatment to 800
mg/m2 due to thrombocytopenia. With cycle 2, she developed a
neutropenia, and with cycle 3, gemcitabine was changed to 1000
mg/m2 days 1 and 15 of a 28-day cycle. Adjuvant therapy
completed ___. Surveillance CT identified bilateral lung
nodules. In ___, Ms. ___ developed ascites and abdominal
CT showed a confluent hypodensity in the liver concerning for
metastasis. This was later felt to be more consistent with
perfusion abnormality.
Social History:
___
Family History:
Family history of DM in her mother and sister. Father died of
cancer (unknown type)
Physical Exam:
Admission Exam
VS T current 97.3 BP 84/58 HR 80 RR 20 O2sat
91% RA 94% 2LNC
Gen: In NAD, pleasant female, thin.
HEENT: EOMI. No scleral icterus. No conjunctival injection.
Mucous membranes slightly dry. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: tachypenic on minimal exertion, decreased to absent BS R
lung ___ up, clear in apex, L clear.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, mild distension, umbilical hernia, RUQ scar,
NABS, no HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3, grossly intact.
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
GU: deferred.
.
Discharge Exam
VS: 97.9 100/52 (96/50-120/70) 86-97) 20 94% RA
Gen: In NAD, pleasant female, thin.
HEENT: NCAT. No scleral icterus. MMM
Lungs: decreased breath sounds on right ___ up lung. Decreased
at left base. no wheezes or crackles
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, mildly distended. nontender. umbilical hernia,
RUQ scar, NABS
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3
Pertinent Results:
admission labs:
___ 02:10PM BLOOD WBC-7.9# RBC-4.05* Hgb-10.8* Hct-31.5*
MCV-78* MCH-26.7* MCHC-34.3 RDW-19.5* Plt ___
___ 02:10PM BLOOD Neuts-95.0* Lymphs-2.5* Monos-1.5*
Eos-0.8 Baso-0.3
___ 02:18PM BLOOD ___ PTT-34.9 ___
___ 02:10PM BLOOD Glucose-201* UreaN-18 Creat-0.9 Na-130*
K-4.8 Cl-92* HCO3-24 AnGap-19
___ 02:10PM BLOOD ALT-34 AST-81* AlkPhos-300* TotBili-1.1
___ 02:10PM BLOOD Lipase-9
___ 02:10PM BLOOD cTropnT-0.01
___ 02:10PM BLOOD Albumin-3.0*
___ 02:19PM BLOOD Lactate-3.6*
.
discharge labs
___ 05:00AM BLOOD WBC-4.2 RBC-3.77* Hgb-9.8* Hct-29.6*
MCV-79* MCH-26.0* MCHC-33.0 RDW-19.6* Plt ___
___ 05:00AM BLOOD Glucose-76 UreaN-8 Creat-0.5 Na-137 K-3.5
Cl-105 HCO3-27 AnGap-9
___ 05:00AM BLOOD ALT-47* AST-56* AlkPhos-353* TotBili-0.4
___ 05:00AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.8
.
pleural fluid
___ 01:00PM PLEURAL WBC-128* RBC-33* Polys-39* Lymphs-28*
Monos-0 Plasma-6* Macro-27*
___ 01:00PM PLEURAL TotProt-2.1 Creat-0.5 LD(LDH)-55
Amylase-1 Albumin-1.0 Cholest-32
.
peritoneal fluid
___ 12:20PM ASCITES WBC-64* RBC-1404* Polys-8* Lymphs-36*
Monos-42* Mesothe-1* Macroph-13*
___ 12:20PM ASCITES TotPro-0.7 Glucose-268 Creat-0.4
LD(LDH)-31 Amylase-1 TotBili-0.1 Albumin-<1.0
.
micro
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
ESCHERICHIA COLI. SECOND MORPHOLOGY. FINAL
SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
ESCHERICHIA COLI. THIRD MORPHOLOGY. FINAL
SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| | ESCHERICHIA
COLI
| | |
AMPICILLIN------------ 4 S <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S S S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ PAGER#
___
ON ___.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
.
blood cx ___ - no growth
urine culture ___ organisms
.
___ 1:00 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
___ 12:20 pm PERITONEAL FLUID CELL BLOCK.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
.
**FINAL REPORT ___
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
cytology
- pericardial, pleural, peritoneal fluid negative for malignant
cells
.
studies
ECHO ___
The left atrium is normal in size. The right ventricular cavity
is mildly dilated with normal free wall contractility. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. No mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade. No right atrial or
right ventricular diastolic collapse is seen.
.
CXR ___
New large right-sided pleural effusion with underlying
atelectasis and possible consolidation in the middle and lower
lobes. CT scan
may offer additional detail of underlying parenchymal
abnormalities. Small
left-sided pleural effusion.
.
CXR ___
Interval decrease in size of right effusion, though a moderate
to
moderately-large right effusion remains. No pneumothorax
detected.
.
CT abdomen and pelvis
1. Status post pylorus-preserving Whipple for pancreatic cancer.
No new mass
or metastatic disease is identified. No evidence of obstruction
or leak.
2. Increased size of large right and moderate left pleural
effusions, now
associated with near total right lower lobe collapse, moderate
right middle
lobe atelectasis, and mild left lower lobe atelectasis.
3. Moderate intrahepatic bile duct dilatation, most severe in
left lobe, not
appreciably changed since ___. No new focal hepatic
collection
or bile duct wall enhancement is present to raise concern for
infection. As
before, hepaticojejunostomy stricture cannot be excluded.
4. Moderate volume ascites, similar to ___ and
slightly
decreased since ___. No evidence of intraabdominal
abscess or
peritonitis.
5. Persistent occlusion of main portal vein, right and left main
portal
veins, upper portion of SMV, and splenic vein.
6. Hypoenhancement of bilateral kidney upper poles with thinned
cortex,
similar to ___ and compatible with prior vascular
injury.
.
CXR ___
Reoccurrence of right-sided pleural effusion in patient with
history of pancreatic carcinoma. No radiographic evidence of
CHF, cardiac
enlargement or fluid overload.
studies
Brief Hospital Course:
___ y/o F with h/o pancreatic cancer who presented with fever to
102 at home, ascites, and new pleural effusion found to have E.
coli bacteremia.
.
# E. coli bacteremia: Blood cultures grew E. coli in 2 of 2
bottles (___). She was initially started on cefepime.
Infectious disease was consulted, and antibiotics were changes
to ceftriaxone when sensitivities returned. Daily cultures were
drawn and remained negative from ___ to ___. The source of the
bacteremia was presumed to be from the gastrointestinal tract.
Recent imaging suggested possible biliary duct dilation and
could not exclude hepaticojejunostomy stricture. She was also
evaluated by the liver team during her hospitalization, and they
agreed that investigation of her biliary tract would be
worthwhile. The patient subsequently underwent ERCP, but the
endoscopists were unable to evaluate the hepatojejunostomy site.
Percutaneous intervention under interventional radiology was
considered, however, given that risks associated with the
procedures and that the patient was clinically improved, the
decision was made not to pursue further investigation at this
time. The patient ultimately had a PICC line placed and was
discharged with plans to complete a course of intravenous
ceftriaxone until ___.
.
# Ascites: Patient reports recurrent ascites since ___ which
is most likely due to portal vein thrombosis. She underwent 2
parcentesis procedures that each drained 1.5L, however, there
was no evidence of SBP. Patient was evaluated by the liver team,
and in addition to investigation of her biliary tract,
recommended that she start a diuretic regimen including lasix
and spironolactone. She was started on both of these medications
which were uptitrated to lasix 40 mg daily and spironolactone
100 mg daily with good urinary output. During her ERCP, grade 2
varices were noted and are likely due to portal vein thrombosis.
Patient would likely benefit from nadolol prophylaxis and this
should be discussed at follow up.
.
# Pleural effusion: Patient found to have new pleural effusion
on admission. Effusion was tapped by the interventional
pulmonary service and fluid was consistent with transudative
process. Echo did not reveal any evidence of heart failure.
Pleural effusion thought to be a result of a ascites. Despite
reaccumulation of fluid, patient denied respiratory distress and
continued to sat in the ___ on room air. She was started on
lasix and spironolactone as described above.
.
# Pancreatic Ca: s/p pancreatoduedenectomy, adjuvant chemo and
radiation, with no documented recurrence although with lung
nodules since ___ and ascites (neg cytology). CA ___ slowly
increasing since ___, suggestive of possible recurrence.
Thus far, there has been no tissue diagnosis of metastasis of
pancreatic cancer but ascites and new lung nodules makes this
highly suspicious. Also patient reports 23 lb unexplained weight
loss which further supports recurrence. Patient was not given
any further treatment for her cancer while in house. Her
cytology of all tapped fluids was negative for malignant cells.
.
# Diarrhea: Patient has hx of IBS however was stooling more
frequently. Stool studies were sent and were negative to date
upon discharged. Her diarrhea slowed and she was discharged home
.
# Anemia: Stable. No evidence of hemolysis. Iron studies did not
suggest iron deficiency.
.
# Diabetes: Patient treated with lantus (16 units) and insulin
sliding scale.
.
# Hyponatremia: Na 130 on admission, likely from hypovolemia,
resolved with IVF.
.
# Portal vein thrombosis: continued Lovenox and treatment of
ascites with diuretics
.
transitional issues
- patient will need to be monitored closely after antibiotics
are stopped for recurrence of bacteremia. If evidence of
recurrent bacteremia, percutaneous interventional procedure
should be considered at that time to further evaluate biliary
tract.
- patient will need to follow up with her primary oncologist as
scheduled. should ensure all age based cancer screening up to
date
- patient's electrolytes will need to be monitored given that
she is on both lasix and spironolactone
- patient was full code during this admission
Medications on Admission:
Medications - Prescription
ENOXAPARIN - 80 mg/0.8 mL Syringe - 70mg subcutaneous injection
daily
FLOROGEN 3 - (Prescribed by Other Provider) - Dosage uncertain
FUROSEMIDE - 40 mg Tablet - 2 Tablet(s) by mouth twice a day
GLIMEPIRIDE - (Prescribed by Other Provider) - 4 mg Tablet - 1
(One) Tablet(s) by mouth once daily in the morning
INSULIN ASPART [NOVOLOG FLEXPEN] - (Prescribed by Other
Provider) - 100 unit/mL Insulin Pen - 4 units three times daily
before meals
INSULIN GLARGINE [LANTUS SOLOSTAR] - (Prescribed by Other
Provider) - 100 unit/mL (3 mL) Insulin Pen - 12 units every
morning
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth twice a day
ZENPEP - (Prescribed by Other Provider) - Dosage uncertain
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
2,000 unit Tablet - 2 Tablet(s) by mouth daily
MULTIVITAMIN - (OTC) - Capsule - one Capsule(s) by mouth
daily
Discharge Medications:
1. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) infusion Intravenous Q24H (every 24 hours).
Disp:*6 infusion* Refills:*0*
2. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous DAILY (Daily).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
5. insulin aspart 100 unit/mL Insulin Pen Sig: Four (4) units
Subcutaneous three times a day: please use before meals .
6. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Twelve
(12) units Subcutaneous once a day.
7. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Three (3) Cap PO QID (4 times a day).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnoses: escherichia coli bacteremia, portal vein
thrombosis
secondary diagnosis: pancreatic cancer, diabetes, anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you while you were admitted to the
hospital. You were admitted because you had shortness of breath
and fever. You were found to have a fluid accumulation in your
lungs which is likely coming from the fluid in your abdomen. You
underwent a few procedures to remove the fluid from your abdomen
and lungs. Evaluation of the fluid did not show any evidence of
infection or cancer. You were evaluated by the liver doctors and
they ___ that the fluid accumulation was due to a large clot in
some of the veins in your stomach. You are already taking
lovenox to treat this.
During your hospitalization, you were also found to have a
bacterial infection your blood stream. You were evaluated by the
infectious disease team and started on an antibiotic called
ceftriaxone to treat this infection. You underwent an a
procedure to evaluate your bile ducts for strictures, however,
given that your post-surgical anatomy, they were unable to reach
the area of concern. We felt that the other procedures to
evaluate this area were high risk and together decided that we
would hold off on further investigation for now.
.
The following changes have been made to your medication regimen.
Please START taking
- ceftriaxone (continue until ___
.
Please CHANGE
- lasix to 40 mg daily
- spironolactone to 100 mg daily
Followup Instructions:
___
|
10410672-DS-17 | 10,410,672 | 26,883,987 | DS | 17 | 2150-05-22 00:00:00 | 2150-05-22 20:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left foot pain
Major Surgical or Invasive Procedure:
Left posterior tibial artery angioplasty and stent.
History of Present Illness:
___ with left foot pain that initially began approximately 1
week ago. Over the past few ays, the pain has increased
significantly, particularly over the
past day. She reports that her pain has prevented her from
ambulating. She was previously ambulating without difficulty.
She also reports that the pain has been extending up her left
eg, and some numbness and tingling in her left leg.
She denies any palpitations, but does have a history of afib,
and is currently treated with coumadin. Of note, she also
recently had a carotid duplex that showed 70-79% stenosis in the
left carotid bulb extending into the origin of the proximal ICA.
She also recently had a right small temporal infarct, and was
treated at ___. She reports that all of her
neurologic
symptoms have resolved since her stroke.
She denies any history of vascular surgeries, but reports that
Dr. ___ her very recently that she needed to have a
carotid endaterectomy.
Past Medical History:
- T2DM c/b retinopathy
- Nonischemic cardiomyopathy, last EF 35% ___
- HTN
- Dyslipidemia
- CVA in ___ with RUE weakness, Subsequent angiography showing
no significant carotid disease, but a left MCA bifurcation 80%
lesion. Subsequent Carotid ultrasound done in ___ did show
70-79% stenosis of the left internal carotid artery; ___
stroke in ___
- afib on Coumadin
- CKD
- h/o DVT
- OA
- spinal stenosis
Social History:
___
Family History:
Mother with CVA and MI at age ___, sister with MI at age ___.
Physical Exam:
Admission Physical Exam:
Gen: no acute distress, alert, responsive
Pulm: unlabored breathing, clear to auscultation bilaterally
CV: afib
Abd: soft, nontender, nondistended
Ext: sensation intact, decreased motor function in left foot
compared to the right (pt reports that this is her baseline
since
her stroke)
L: p/p/d/d
R: p/p/d/d
Discharge physical exam:
Vitals: 99.___/98.2 85 130/67 18 97RA
General: lying in bed, NAD
Pulm: CTAB/L
CV: afib
Abd: soft, nontender, nondistended, +BS
Ext: sensation intact, decreased motor function in left foot
from prior stroke
L: p/p/d/d
R: p/p/d/faint
Pertinent Results:
Labs:
___ 05:56AM BLOOD WBC-7.2 RBC-3.75* Hgb-9.5* Hct-30.3*
MCV-81* MCH-25.3* MCHC-31.3 RDW-16.4* Plt ___
___ 05:56AM BLOOD Glucose-207* UreaN-45* Creat-2.5* Na-143
K-3.7 Cl-108 HCO3-23 AnGap-16
___ 05:56AM BLOOD Calcium-8.4 Phos-5.3*# Mg-2.2
___ 01:14AM BLOOD Digoxin-0.2*
Imaging
___: Carotid duplex
Impression: Right ICA with less than 40% stenosis.
___: Foot x-ray
Impression No acute fracture.
___: ABI/PVR
Right ABI 0.35, Left ABI 0.46
Severe outflow arterial disease in the bilateral lower
extremities at the
level of the distal popliteal and/or tibial arteries.
___: arterial duplex
No popliteal aneurysms.
___: aortic ultrasound
1. Non aneurysmal abdominal aorta with moderate atherosclerosis.
2. Mild ectasia of the proximal abdominal aorta.
___: CXR
Heart size is substantially enlarged including a left ventricle
left atrium and most likely the right side of the heart. There
is currently a mild vascular engorgement but no overt pulmonary
edema demonstrated. No pleural effusion or pneumothorax seen.
___: right lower extremity duplex
1. Occlusion of the right peroneal artery.
2. Evidence of peripheral arterial disease with monophasic
waveforms
identified in the vessels distal to the right popliteal artery.
___: ABI/PVR
Right ABI 0.35 Left ABI 0.56
Severe outflow arterial disease in the bilateral lower
extremities of the tibial arteries.
___: right arterial duplex
Patent flow through right femoral artery.
Brief Hospital Course:
Patient was admitted to the vascular surgery service for further
management of worsening left foot pain for 1 weeks. Of note,
patient has atrial fibrillation. Admission INR was 2.8 so it is
unlikley that she embolized a clot from a cardiac origin.
However, it is unknown what here INR was 1 week ago when she
started having the pain. Heparin was started with a PTT goal of
60-80 for treatment of a suspected thrombus or clot.
On HD2, noninvasive vascular studies were performed. ABI/PVR
showed right ABI 0.35, left ABI 0.46, and waveforms showed
severe outflow arterial disease in the bilateral lower
extremities at the level of the distal popliteal and/or tibial
arteries. Becuase of concern for microembolization, ultrasound
studies were performed and showed no abdominal aortic aneurysm
or popliteal aneurysm present. Patient received Vitamin K for an
INR of 3 in prepreation for angiogram the following day. Repeat
INR the following day was 1.6.
On ___, patient was taken for angiogram of her left foot via
a right groin access. Angiogram showed single vessel runoff to
her foot (posterior tibial). The AT and peroneal arteries were
both occluded. The proximal one-third of the posterior tibial
artery was occluded. Per the vascular surgeons, the proximal
occulsion appeared acute. Distally, the ___ occlusion appeared
chronic baised on the number of collateral arteries. Balloon
angioplasty was performed and stent was placed in the proximal
___, with resulting patency of the proximal ___ occlusion.
Postoperative, the patient was start on Plavix. The plan was to
continue patient on warfarin + plavix for one month and then
warfarin + aspirin indefinitely. Patient was restarted on
heparin postoperatively. On POD#2, patient developed coolness of
her right foot with worsened doppler signals of the ___.
Aterial duplex of her right leg showed Occlusion of the right
peroneal artery and evidence of peripheral arterial disease with
monophasic waveforms identified in the vessels distal to the
right popliteal artery. The team was concerned for
microembolization or thrombus from the right groin access site.
Therefore, ABI/PVR and right arterial duplex was performed
showing patent flow through the right femoral artery. Because
post-angio renal function worsened(Cr increased from 2.0 to
2.5), patient was transferred to acute rehab with heparin gtt
and will be readmitted to ___ next ___ night for
prehydration for angiogram of right lower extremity on ___
(___).
Rheumatology was consulted during this admission regarding the
left foot pain. Per rheumatology, her foot pain along the
plantar aspect was consistent with plantar fasciitis. Because of
tenderness along the lateral aspect of the fifth metatarsal,
there was concern for an underlying fracture desipite negative
foot x-rays on admission. MRI of left foot was planned for
further evaluation. However, MRI was not performed because MRI
scheduling issues. It was decided that the patient would receive
an MRI, if necessary, next week on readmission.
During this admission, patient's hypertension was difficult to
control. Home metoprolol was switched to lebetalol 100TID.
Patient failed trial of void after ___ was DC. Foley was
reinserted and patient was transferred to rehab with foley.
Prior to discharge, patient received a PICC placement for
heparin gtt at acute rehab. PICC placement was confirmed with
x-ray.
Medications on Admission:
albuterol, allopurinol ___ mg', atorvastatin 80 mg', buspirone 5
mg tablet' in AM, buspirone 5mg' at noon, buspirone 5mg' in ___,
calcitriol 0.5 mcg', digoxin 0.125 mcg MWF, fluticasone 50
mcg/actuation nasal', Flovent HFA 220 mcg/actuation aerosol'',
furosemide 40 mg MWF, gabapentin 300 mg', glipizide 15 mg'',
Novolog Flexpen 100 unit/mL ISS, Lantus Solostar 22 U HS,
lisinopril 30 mg', meclizine 12.5 mg Q6H, metoprolol succinate
ER 200 mg', prednisone 30 for gout flares, warfarin 5 mg',
Tylenol ___ mg'', Ri-Mox Plus 225 mg-200 mg-25 mg/5 mL 30 ml by
mouth q 4 hrs prn, Aspirin 81 mg', bisacodyl 10 mg' prn, Humulin
R 100 unit/mL ISS, loratadine 10 mg', Milk of Magnesia 400mg/5
mL oral suspension 30 ml qd prn, Ferrex ___ mg iron'', Fleet
Enema 19 gram-7 gram/118 mL 2 enema(s) prn if MOM and ___
ineffective
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. BusPIRone 5 mg PO QAM
7. BusPIRone 5 mg PO NOON
8. BusPIRone 10 mg PO HS
9. Calcitriol 0.5 mcg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Digoxin 0.125 mg PO 3X/WEEK (___)
12. Docusate Sodium 100 mg PO BID
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. Furosemide 40 mg PO DAYS (___)
16. Gabapentin 300 mg PO DAILY
17. GlipiZIDE 15 mg PO BID
18. Heparin IV Sliding Scale
Continue existing infusion at 1100 units/hr
Start: Now
Target PTT: 60 - 80 seconds
19. Glargine 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
20. Labetalol 100 mg PO TID
21. Lisinopril 30 mg PO DAILY
22. Meclizine 12.5 mg PO Q6H:PRN dizziness
23. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 2.5 mg by mouth every 4 hours Disp #*40
Capsule Refills:*0
24. Polyethylene Glycol 17 g PO DAILY
25. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left foot pain likley secondary to posterior tibial artery
occlusion.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATION:
Take Aspirin 81mg (enteric coated) once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Do not take the Warfain. You will continue anticoagulation
with heparin. We will restart your Warfarin after the angiogram
next ___. Continue all other medications you were taking
before surgery, unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
10410752-DS-21 | 10,410,752 | 24,721,261 | DS | 21 | 2128-07-28 00:00:00 | 2128-07-30 09:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with past medical history significant
for MI ___, ?heart failure, HTN, and arthritis who presents
with lightheadedness and diaphoresis. Patient reports that this
morning she was at a breakfast banquent when she had a sudden
onset of lightheadedness shortly after sitting down. She had a
few bites of her breakfast when her friend noticed she was pale
and sweating profusely. Her symptoms lasted for several minutes
and resolved after she was eased down to the floor by her
friends. A doctor from ___ neighboring ___ hall was called who
noted that her pulse was fast. The patient wanted to finish her
breakfast, but EMS was called and she was brought to the ED.
In the ED, initial vitals were T 96.6 HR 61 BP 101/44 RR 20 Sat
95% RA. Her exam was notable for normal neurological exam and
regular rate and rhythm. Labs showed creatinine 2.0 and neg
troponin. CXR without any acute processes. Patient was admitted
for further workup and management of ___.
On arrival to the floor, patient reports complete resolution of
her symptoms. She notes that she had no prior similar episodes.
She has a history of mechanical falls, which she clearly
remembers and involve tripping while carrying heavy bags down
stairs or slipping on wet floors at the grocery store. She
denies chest pain, palpitations, shortness of breath,
unsteadiness, vertigo, headache, visual changes, or neck
stiffness. She also denies fever, chills, n/v, cough, abd pain,
changes in BM, dysuria. She does note intermittent urinary
urgency over the past ___ months. Also notes an 8lb weight loss
over the past year, appetite unchanged.
Of note, patient had an inferior MI in ___ that resulted in
cardiac arrest requiring CPR and intubation. At the time, family
opted for medical management and patient did not undergo cardiac
cath or CABG.
Past Medical History:
CAD with MI ___
Cataract surgery ___
HTN
HLD
Arthritis
Chronic Back pain
Social History:
___
Family History:
Mother- diabetes
Father- heart disease
Brother- diabetes
Sister- heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: T 97.5 132/81 81 18 98 RA
GENERAL: elderly woman lying comfortably in bed, alert and
awake, breathing comfortably, speaking in full sentences, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry mucus membranes, no LAD
HEART: RRR, nml S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: +BS, soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: WWP, normal capillary refill, no cyanosis, clubbing
or edema; moving all 4 extremities with purpose
NEURO: CN III-XII intact, ___ strength all extremities,
sensation grossly intact, no pronator drift, normal
finger-nose-finger test, normal gait
DISCHARGE PHYSICAL EXAM:
=======================
VS: 97.4PO 122/67 61 18 98 Ra
GENERAL: elderly woman lying comfortably in bed, alert and
awake, breathing comfortably, speaking in full sentences, in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry mucus membranes, no LAD
HEART: RRR, nml S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: +BS, soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: WWP, normal capillary refill, no cyanosis, clubbing
or edema; moving all 4 extremities with purpose
NEURO: CN III-XII intact, ___ strength all extremities,
sensation grossly intact, no pronator drift, normal
finger-nose-finger test, normal gait
Pertinent Results:
___ LABS:
==============
___ 10:16AM BLOOD WBC-9.0 RBC-5.52* Hgb-12.4 Hct-39.0
MCV-71* MCH-22.5* MCHC-31.8* RDW-16.0* RDWSD-39.0 Plt ___
___ 10:16AM BLOOD Neuts-65.8 ___ Monos-8.3 Eos-2.6
Baso-0.4 Im ___ AbsNeut-5.89 AbsLymp-2.01 AbsMono-0.74
AbsEos-0.23 AbsBaso-0.04
___ 10:16AM BLOOD Glucose-160* UreaN-36* Creat-2.0*# Na-135
K-4.7 Cl-96 HCO3-25 AnGap-19
___ 10:16AM BLOOD cTropnT-<0.01
___ 10:16AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.0
NOTABLE LABS:
=============
___ 05:46AM URINE Hours-RANDOM UreaN-670 Creat-180 Na-31
___ 05:46AM URINE Osmolal-440
___ 10:16AM BLOOD UreaN-36* Creat-2.0*#
___ 07:15AM BLOOD UreaN-47* Creat-1.7*
DISCHARGE LABS:
==============
___ 07:15AM BLOOD WBC-7.1 RBC-5.07 Hgb-11.4 Hct-36.1
MCV-71* MCH-22.5* MCHC-31.6* RDW-15.9* RDWSD-39.7 Plt ___
___ 07:49AM BLOOD Glucose-92 UreaN-30* Creat-1.0 Na-141
K-4.3 Cl-105 HCO3-26 AnGap-14
___ 07:49AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.5
IMAGING:
=========
___ (PA & LAT)
No acute cardiopulmonary abnormality.
___ TTE
The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated. There is mild regional left
ventricular systolic dysfunction with basal to mid inferoseptal
and inferior hypo-/akinesis and apical inferior hypokinesis.
Doppler parameters are most consistent with Grade II (moderate)
left ventricular diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is no
mitral valve prolapse. An eccentric, posteriorly directed jet of
Mild to moderate (___) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION:
1) Mild regional left ventricular systolic dysfunction c/w piror
myocardial infarction in the PDA distribution.
2) Grade II LV diastolic dysfunction.
3) Mild to moderate posteriorly directed mitral regurgitation.
Mechanism of mitral regurgitation is likely calcified posterior
mitral leaflet with limited excursion during both
systole/diastole.
Compared with the prior study (images reviewed) of ___,
findings are similar. The severity of mitral regurgition has
increased.
Brief Hospital Course:
___ year old female with past medical history significant for MI
___, systolic heart failure (EF 40% in ___, HTN, and
arthritis who presented with lightheadedness and diaphoresis,
found to have ___ and enterococcus UTI. Patient had been started
on bumetanide for her heart failure 4 months prior and patient
noted increased urinary frequency with the medication (she
reports only taking once daily instead of the prescribed twice
daily). On admission, patient's symptoms had resolved and her
physical exam, including a comprehensive neurological exam, was
unremarkable. She was placed on telemetry and noted to be in
sinus rhythm with a rate ___. She was noted to be
hypovolemic on exam, her diuretic was held, and she was given a
gentle 500 cc bolus of fluids. Her valsartan was also held given
her ___. Her FeNa was noted to be 0.03%, making her ___
consistent with a pre-renal insult. Her creatinine had
moderately improved with the initial bolus and she was given a
second gentle bolus. She had a TTE which was similar to prior.
Her diuretic was held. Her ___ improved; however, her valsartan
was continued to be held. Patient was also found to have urinary
urgency and an outpatient urine culture positive for
pan-sensitive enterococcus, for which she was started on a 7 day
course of ampicillin (___). Patient continued to be
asymptomatic and was discharged home with close PCP ___.
#Presyncope: patient with episode of lightheadedness and
diaphoresis with reported elevated HR. Symptoms resolved after
few minutes of lying down on ground. Trop neg, EKG with sinus
rhythm, first degree heart block, and evidence of prior MI, no
evidence of new ischemic changes. Neuro exam intact. Mostly
likely secondary to dehydration in setting of diuretic use. This
is supported by positive orthostatic vital signs and pre-renal
___. Differential also includes new arrhythmia (given history of
prior inferior wall MI and reported tachycardia during episode),
infectious (patient with enterococcus UTI), and vasovagal.
Patient was maintained on telemetry, which revealed no events.
TTE was performed which was similar to her prior TTE from ___.
She improved with hydration and repeat orthostatics were
negative. Patient was discharged without restarting her
diuretics and with close PCP ___
#Acute kidney injury: patient with baseline creatinine 0.9-1.0;
cr 2.0 on admission. Recently placed on diuretic by PCP 4 months
ago. FeNa 0.3%, making pre-renal etiology most likely. Improved
with gentle fluid bolus. Creatinine was trended and improved to
1.0 prior to discharge. Valsartan, bumex, and NSAIDs held.
#Systolic heart failure without acute exacerbation:
- Diuretics held upon discharge. Patient was only taking
bumetanide 1mg once daily instead of the prescribed twice daily
prior to admission, yet she became dehydrated, developed acute
kidney injury, orthostasis, and presyncope, so it was held on
discharge.
- Patient has ___ with her cardiologist less than one week
after discharge and would recommend decreasing the dose of her
diuretics and monitoring weights, renal function, and blood
pressures closely
#Urinary tract infection: patient with urinary urgency and found
to have pan-sensitive enterococcus on UCx ___. Has multiple
prior UCx positive for pan-sensitive enterococcus over the past
6 months. She was started on ampicillin 500 mg PO Q8H x7 days
(___).
TRANSITIONAL ISSUES:
===================
[] Patient with TTE was stable from prior (LVEF 40%).
[] Patient's bumetanide was discontinued. Please follow up
patient's volume status and consider restarting her diuretic at
a decreased dose. Patient counseled to carefully monitor her
weight daily
[] Discharge creatinine 1.0
[] Patient found to have urinary urgency and pan-sensitive
enterococcus on urine culture. She was started on a 7 day course
of ampicillin (___). Please follow up with patient
on resolution of her urinary symptoms.
CODE STATUS: FULL
CONTACT: ___ (son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 6.25 mg PO BID
2. Valsartan 160 mg PO DAILY
3. Naproxen 500 mg PO Q12H
4. Atorvastatin 40 mg PO QPM
5. FoLIC Acid 1 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Aspirin 325 mg PO DAILY
8. Bumetanide 1 mg PO BID
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Ampicillin 500 mg PO Q8H
Last day: ___
RX *ampicillin 500 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*13 Capsule Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Carvedilol 6.25 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Naproxen 500 mg PO Q12H
9. HELD- Valsartan 160 mg PO DAILY This medication was held. Do
not restart Valsartan until your cardiologist tells you to do
so.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
Dehydration
Acute Kidney Injury
Urinary Tract Infection, Complicated
SECONDARY DIAGNOSES:
====================
Systolic Heart Failure
CAD
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were recently hospitalized at ___
___. Below is a description of your hospital stay.
WHY YOU WERE HERE?
===================
- You were admitted for lightheadedness and sweating, likely due
to dehydration. You were also found to have kidney injury and an
infection in your urine.
WHAT HAPPENED WHILE YOU WERE HERE?
===================================
- For your lightheadedness, you were given fluids.
- You also had an ultrasound of your heart, which showed no
changes from your prior echo. This was good news!
- For your kidney injury, you were given fluids and they
improved
- For your urine infection, you were started on antibiotics
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
============================================
- Take all of your medications as prescribed.
- STOP taking your bumex. This dehydrated you.
- Follow up with your primary care doctor on ___ for your heart, kidneys, and urine infection.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
It was a pleasure taking care of you.
Your ___ Team
Followup Instructions:
___
|
10410774-DS-18 | 10,410,774 | 21,942,478 | DS | 18 | 2166-01-25 00:00:00 | 2166-01-25 17:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___- CT-guided left inguinal lymph node bx
___- Craniotomy for R parietal mass resection
History of Present Illness:
Ms ___ is a ___ yr old female w/ hx of stage IA large cell
carcinoma of lung s/p resection in ___ and lymphadenopathy of
unclear etiology followed by Drs ___ since ___ w/
serial scans, see history below. She had bipsy of endobronchial
mass in ___ ___s RLL mass in ___ w/ atypical lymph
population and inguinal LN in ___ that was most c/w w/ benign
LN.
She presents to ED last night w/ worsening lower ab discomfort
she describes as intermittent sharp pain that radiates to the
back. Also nausea w/o vomiting, very poor appetite and PO intake
and DOE. Has hx of COPD, takes Spiriva and rarely uses
albuterol, has not used her inhaler in the past week although
she
does endorse her activity is more limited on exertion. On
arrival to floor she was quite winded after getting up to
bathroom. She was planning to stay in her cottage up ___ this
week but after one day felt she couldn't do it anymore and came
in to ED. She feels anxious to be away from her family as her
daughter is being treated for ovarian cancer.
She has some intermittent nonproductive cough, no hemoptysis.
Denies fever/chills or sweats. Denies any enlarging lumps/bumps.
No vomiting. Cant remember if had BM in the past week as she has
been taking almost nothing, typically has regular BM. Is able to
drink liquids ok. has very dry mouth and thirst.
In ED she underwent CT ab that showed worsening RP LAD, now
w/involvement of pelvic side wall. was also noted to have temp
100.2 on arrival. she was given morphine IV, Zofran and 1L NS in
ED and admitted to oncology for further eval.
Past Medical History:
PAST ONCOLOGIC HISTORY: per OMR
ONCOLOGIC HISTORY:
--___: had a stage IA large cell carcinoma of the lung
resected.
--___: CT chest showed a new endobronchial lesion in the
right upper lobe. This was biopsied which showed atypical
lymphoid aggregates. B-cell receptor gene rearrangement showed
one primer set that was suggestive of clonality; however, the
other two primer sets were not. Given the uncertainty of the
diagnosis, she underwent repeat chest CT in ___ and ___, which showed clinical
resolution of the right upper lobe process with a new right
lower
lobe nodule and an increase in the left lower lobe anteromedial
segment.
--___: repeat chest CT showed enlargement of the right
lower lobe endobronchial lesion as well as increased mediastinal
and hilar lymphadenopathy. Biopsy of right lower lobe mass
showed an atypical lymphocytic, histiocytic infiltrate with
fibrosis. AFB, GMS and Gram stains were negative for
microorganisms. Immunohistochemical stains reveal a
morphologically atypical lymphoid population consisting of mixed
CD3 positive and CD5 positive T cells and CD20 B cells with a
low
proliferative index, approximately 10% by Ki-67 staining. The
overall findings are nonspecific but raise concern for a
hemato-lymphoid neoplasm. Clonality could not be determined due
to the presence of a wash-resistant cytophilic antibody.
--___: PET/CT showed extensive FDG avid lymphadenopathy
including mediastinal, hilar, axillary, internal mammary,
paraesophageal, retrocrural, periportal, retroperitoneal, pelvic
and inguinal. FDG avid right lower lobe endobronchial mass.
Left
intraparotid node with FDG avidity could reflect a pleomorphic
adenoma.
- ___ CT torso showED mediastinal adenopathy measuring up to
3.4 cm along with multiple other areas including periaortic
retrocrural and hilar nodes
- ___ ___ torso: all areas generally decreased in size,
including small enlarged lymph nodes just inferior to the carina
and the posterior mediastinum posterior to the esophagus
measuring up to 1.3 cm. No supraclavicular or axillary
adenopathy. and in addition, her retroperitoneal nodes from
___ similarly measured up to 2.3 cm in size, which is
slightly decreased compared to her ___ study
OTHER PMH:
1. Large cell lung cancer status post resection in ___.
2. COPD.
3. Type 2 diabetes.
Social History:
___
Family History:
No family hx heme malignancies. Daughter with ovarian cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
General: NAD
VITAL SIGNS: 99.0 140/60 85 42 95% 2L
HEENT: MM dry lips crusted, no OP lesions no thrush or ulcers
Neck: supple, no JVD
Lymph: no prominent cervical, supraclavicular, axillary
adenopathy, has fullness and discomfort in L inguinal region but
unable to appreciate discrete mass
CV: RR, NL S1S2 no S3S4 or MRG
PULM: tachypneic w/ shallow breathing w/o retractions, talking
in full sentences, decreased bibasilar R>L no wheezing or
crackles
ABD: BS+, soft, mod distended, currently nontender,
splenomegaly
to L ilium although was in very upright position due to concern
for worsening resp status w/ lying flat
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion and hip flexion against
resistance bilateral, sensation intact to light touch, no clonus
DISCHARGE PHYSICAL EXAM
=======================
___: A&Ox3. motor ___. speech is clear, no deficits. incision
closed with sutures/staples, CDI- ecchymosis at incision site
Pertinent Results:
ADMISSION LABS
==============
___ 05:50PM GLUCOSE-228* UREA N-25* CREAT-0.8 SODIUM-128*
POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-22 ANION GAP-20
___ 05:50PM estGFR-Using this
___ 05:50PM ALT(SGPT)-9 AST(SGOT)-17 LD(LDH)-302* ALK
PHOS-85 TOT BILI-1.5
___ 05:50PM LIPASE-9
___ 05:50PM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-2.7
MAGNESIUM-1.8 URIC ACID-6.2*
___ 05:50PM LACTATE-1.4
___ 05:50PM WBC-8.5 RBC-3.53* HGB-11.4 HCT-33.6* MCV-95
MCH-32.3* MCHC-33.9 RDW-15.3 RDWSD-52.3*
___ 05:50PM NEUTS-83.1* LYMPHS-7.6* MONOS-7.3 EOS-0.6*
BASOS-0.6 IM ___ AbsNeut-7.04* AbsLymp-0.64* AbsMono-0.62
AbsEos-0.05 AbsBaso-0.05
___ 05:50PM PLT COUNT-238
MICROBIOLOGY
==============
UA (___): wnl
BCx ___: pending
UCx (___):
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
PATHOLOGY
==============
Inguinal node biopsy (___):
1. Lymph node, #1, left inguinal biopsy: Metastatic carcinoma,
consistent with lung origin. See note.
2. Lymph node, #2, left inguinal, biopsy: Metastatic carcinoma,
consistent with lung origin, see note.
Note: The tumor has the following immunohistochemical profile:
CK7 (positive), TTF-1 (positive), Napsin (positive), p40
(focally positive) and CK20 (negative). The tumor is
morphologically similar to
the patient's prior left upper lobe lung wedge resection
specimen (___).
IMAGING
==============
CXR (___):
IMPRESSION:
1. New small bilateral pleural effusions and patchy bibasilar
airspace opacities which may reflect infection or aspiration.
2. New convex soft tissue density lateral to the aortic knob
could reflect new prevascular lymphadenopathy. Follow-up chest
CT is recommended.
3. Moderate size hiatal hernia.
CT chest w/o contrast (___):
IMPRESSION:
1. Interval enlargement of multiple pulmonary nodules and
lymphadenopathy.
2. Consolidation in the right lower lobe could be pneumonia or
pulmonary lymphoma, and consolidation in the left lower lobe is
more likely atelectasis.
3. Moderate right and small left pleural effusions are non
serous and
nonhemorrhagic.
CT abdomen w/o contrast (___):
IMPRESSION:
1. Extensive soft tissue confluent lymphadenopathy with central
necrosis in the retroperitoneum, retrocrural posterior
mediastinum, pelvic side wall, and inguinal regions, progressed
from the prior exam. The differential includes metastasis,
previously partially treated lymphoma, or mycobacterial disease.
2. Distal IVC is patent but demonstrates compression by the
enlarged lymph nodes.
3. New splenic and hepatic hypodensities since ___ are
concerning for metastasis in the setting of extensive
lymphadenopathy.
4. Splenomegaly.
5. New bilateral, nonhemorrhagic moderate right and small left
pleural effusions.
6. Bilateral right worse than left aspiration and/or concurrent
infection, likely related to large hiatal hernia.
CT chest w/o contrast (___):
IMPRESSION:
1. Interval enlargement of multiple pulmonary nodules and
lymphadenopathy.
2. Consolidation in the right lower lobe could be pneumonia or
pulmonary lymphoma, and consolidation in the left lower lobe is
more likely atelectasis.
3. Moderate right and small left pleural effusions are non
serous and
nonhemorrhagic.
Brain MRI w/contrast (___):
IMPRESSION:
1. Severe motion artifact which significantly degrades spatial
resolution. Consider repeat MRI and patient can tolerate.
2. Lobular peripherally enhancing mass centered at the right
parieto-occipital cortex extending to the right tentorial falx
and/or right occipital horn lateral ventricle. Associated
internal hemorrhage with a layering hematocrit level. Severe
adjacent vasogenic edema without midline shift or downward
herniation. Findings highly suspicious for neoplasm with
differential including metastatic disease or high-grade primary
CNS neoplasm. Central
necrosis and hemorrhage is atypical for primary CNS lymphoma
unless the patient is immunocompromised.
3. Layering signal within the left occipital horn without
definite
enhancement. Finding may represent blood products,
proteinaceous or cellular debris (possibly from infection), or
intraventricular disease. Consider CT or repeat MRI to further
characterize.
4. Heterogeneous signal and enhancement throughout the
calvarium, skull base, and visualized cervical spine suspicious
for diffuse osseous disease, given the systemic disease seen on
prior chest and abdomen pelvis CT.
CT Head w/o Contrast (___):
IMPRESSION:
1. Lobulated hypodense mass centered at the right occipital
parietal cortex, better characterized on prior MRI with
unchanged posterior layering hemorrhage.
2. Layering fluid within the occipital horn of the left lateral
ventricle without acute hemorrhage.
MRI FUNCTIONAL BRAIN (___):
IMPRESSION:
1. Unchanged ring-enhancing lesion within the right occipital
and inferior
aspect of the right parietal lobes, with stable mass effect.
There is no
evidence of increased perfusion in this mass.
2. There is no evidence of significant BOLD activation areas
adjacent to this mass lesion.
3. The tractography color maps demonstrate tracts and fibers
corresponding
with the lateral reflection of the corpus callosum and inferior
longitudinal fasciculus lateral lateral to this lesion.
DX CHEST PORTABLE PICC (___)
IMPRESSION:
There has been interval removal of the right-sided PICC line and
placement of a new left-sided PICC line. The new PICC line tip
is in the right atrium.
This can be pulled back 3 cm to be at the cavoatrial junction.
There
continues to be dense bilateral lower lobe volume loss/
infiltrate and
probable bilateral small pleural effusions. There is be
pulmonary vascular redistribution and ___ B-lines compatible
fluid overload.
___ CT head
Interval right parietal craniotomy for surgical resection with
expected
small volume of fluid and trace blood products in the surgical
bed. No
evidence of large territory infarct.
MR HEAD W & W/O CONTRAST Study Date of ___ 8:33 ___
IMPRESSION:
1. Residual rim enhancement at the superior aspect of the right
parieto-occipital resection cavity which closely mirrors the
margins of the preoperative examination, and is highly
suspicious for residual tumor.
2. Diffuse calvarial bone marrow heterogeneity with areas of
patchy
enhancement concerning for diffuse osseous metastasis.
3. Otherwise expected postoperative changes from right
parieto-occipital
craniotomy and mass resection.
Brief Hospital Course:
ONCOLOGY SERVICE HOSPITAL COURSE
================================
Ms. ___ is a ___ with hx of stage IA large cell lung
carcinoma s/p resection in ___, with subsequent development of
mediastinal and inguinal LAD, endobronchial and RLL
consolidation, with biopsies through ___ significant for only
atypical B and T cell lymphoid aggregates. She is admitted with
1 week of worsening nausea/reduced PO intake/constipation,
abdominal pain, dyspnea on exertion, and persistent headaches,
and found to have progressive mediastinal and abdominal
lymphadenopathy w/ biopsy proven lung adenocarcinoma, brain
metastasis, presumed to be adenocarcinoma, and obstructive PNA.
#Brain metastasis: On admission, patient endorsed persistent
frontal HA, that improves with ibuprofen, improves in supine
position; patient denies light/noise sensitivity/aura.
Differential brain mets versus migraine. Brain MRI ___ showed
lobular, peripherally enhancing mass centered at the R
parieto-occipital cortex extending to the R tentorial falx
and/or right occipital horn lateral ventricle with internal
hemorrhage and a layering hematocrit level; Severe adjacent
vasogenic edema without midline shift or downward herniation.
Concerning for metastatic disease, likely from primary lung
adenocarcinoma (must r/o breast) given pt's hx and
adenocarcinoma identified on retroperitoneal lymph node biopsy,
much less likely lymphoma given internal hemorrhage/neoplasm and
lobular shape. Rad onc will defer consult until after brain
resection. Patient had pre-surgery MRI wand and NCHCT on ___
and fMRI on ___. Continue keppra 500 mg bid and continue
dexamethasone. Transferred to neurosurgery service on ___.
From ___ the patient remained inpatient on the
neurosurgery service for close neurologic monitoring. She
remained neurologically and hemodynamically stable.
On ___, the patient was taken to the OR for craniotomy for
tumor resection. Procedure was uncomplicated and well tolerated.
She was transferred to the ICU for post operative monitoring.
Post operative Head CT revealed expected changes. On POD#1
patient remained neurologically intact and was transferred from
the ICU to the floor. She underwent a post operative MRI which
revealed 1. Residual rim enhancement at the superior aspect of
the right parieto-occipital resection cavity which closely
mirrors the margins of the preoperative examination, and is
highly suspicious for residual tumor. 2. Diffuse calvarial bone
marrow heterogeneity with areas of patchy
enhancement concerning for diffuse osseous metastasis. 3.
Otherwise expected postoperative changes from right
parieto-occipital craniotomy and mass resection.
#metastatic carcinoma/lymphadenopathy: Pt's nausea and abdominal
pain likely ___ to progressive chest and abdominal LAD. CT chest
and abdomen (___) demonstrate progressive, extensive
lymphadenopathy in the chest, retroperitioneal and inguinal
regions involving the pelvic side wall, and splenomegaly.
Differential includes DLBCL versus double-hit lymphoma vs lung
cancer metastasis. LDH 252, uric acid 6.6. Hep A, Hep B, HIV
serologies negative. Inginual LN biopsy with ___ ___, consistent
with adenocarcinoma, likely from her lung primary given pos CK7
and TTF-1. PICC placed ___, but came out on ___. Quantiferon Tb
test ___ negative. Received B12 1000 IM x 1 on ___ and
started and folate 1mg po daily on ___ in preparation of Tx with
likely Pemetrexed ___ weeks post-nsgy. Continued Allopurinol ___
mg qd. Continued folate 1mg po daily in preparation of Tx with
likely Pemetrexed
- will need to be started on B12 1000 IM q8weeks as an
outpatient
#?Obstructive Pneumonia: Pt has dyspnea on exertion that
required 2LNC yesterday, but has improved, back to RA. CT shows
new RLL and LLL consolidations, likely obstructive PNA versus
lymphadenopathy. Also bilateral pleural effusions. UCx negative.
Levofloxacin, 7 day course, start ___, end ___
#Hyponatremia: chronic during this admission, ~NA 130. Likely
was initially ___ to hypovolemia iso nausea and improved
temporarily with IVF; higher suspicion for SIADH now given
chronicity, brain metastasis. Currently improved to 135 iso of
being NPO, c/w SIADH, although lower FSBGs yesterday (92-33).
Patient required hypertonic saline during her craniotomy for
persistent hyponatremia. Post operative hypertonic saline was
discontinued and sodium was monitored closely.
#Insomnia: continues to endorse difficulty sleeping, likely ___
to dexamethasone; not responsive to trazodone. Ativan 0.5 mg QHS
PRN
#Nausea/constipation: likely ___ mass effect of progressive
lymphadenopathy; patient not currently having nausea. Treated
with Zofran. Aggressive bowel reg with senna/Colace, Mg citrate,
Miralax for now
#Dyspnea/COPD: RA at baseline. was dyspneic and required 2L at
time of admission. still dyspneic, but now satting well on RA.
likely ___ mass effect of progressive lymphadenopathy. Duonebs
as needed and continued home spiriva
#Type 2 DM: diet controlled at home with glargine 42U qAM. BG
221-298 until starting dexamethasone yesterday. Sugars spiked to
487 on ___. Required 38U of Humalog to bring FSBG to 124.
Adjusted glargine and ISS on ___, with FSBG 92-233 on ___
(although NPO). On ___ the patient had post breakfast
hyperglycemia with a FSBS of 429, she received 14 units of
Humalog per the insulin sliding scale as well as 45 units of
Lantus. ___ was consulted and her sliding scale insulin scale
was adjusted and her dexamethasone dose was tapered.
Transitional:
[] will need B12 1000 IM q8weeks as outpatient for chemo (likely
___ post-nsgy)
On day of discharge she was stable and cleared for home with ___
and OT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Glargine 42 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Aspirin 81 mg PO DAILY
4. albuterol sulfate 90 mcg/actuation inhalation q4 hr prn SOB,
wheezing
Discharge Medications:
1. Glargine 45 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*6
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
10. Sodium Chloride 1 gm PO TID
RX *sodium chloride 1 gram 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
11. Tiotropium Bromide 1 CAP IH DAILY
12. albuterol sulfate 90 mcg/actuation inhalation q4 hr prn SOB,
wheezing
13. Dexamethasone 3 mg PO Q8H Duration: 6 Doses
This is dose # 2 of 5 tapered doses
RX *dexamethasone 2 mg 1.5 tablet(s) by mouth every eight (8)
hours and taper as directed Disp #*60 Tablet Refills:*0
14. Dexamethasone 2 mg PO Q8H Duration: 6 Doses
This is dose # 3 of 5 tapered doses
Tapered dose - DOWN
15. Dexamethasone 1 mg PO Q8H Duration: 6 Doses
This is dose # 4 of 5 tapered doses
Tapered dose - DOWN
16. Dexamethasone 1 mg PO Q12H Duration: 4 Doses
This is dose # 5 of 5 tapered doses
Tapered dose - DOWN
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Metastatic lung carcinoma
SECONDARY DIAGNOSES:
Diabetes
Chronic Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___. You were found
to have a new brain mass and enlarged lymph nodes in your
abdomen. A biopsy showed that this was due to your prior lung
cancer that has now spread. You had brain surgery to remove the
mass.
Neurosurgery Discharge Instructions
Surgery
You underwent surgery to remove a brain lesion from your
brain.
Please keep your incision dry until your sutures and staples
are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You can restart your Aspirin 7 days after surgery on
___
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
**** Dexamethasone Taper:
3mg (1.5 tablets) by mouth every 8hrs for 5 doses then
2mg (1 tablet) by mouth every 8hrs for 6 doses then
1mg (half tablet) by mouth every 8hrs for 6 doses then
1mg (half tablet) by mouth every 12hrs for 4 doses then stop.
Followup Instructions:
___
|
10410774-DS-19 | 10,410,774 | 29,581,239 | DS | 19 | 2166-02-04 00:00:00 | 2166-02-04 10:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
aphasia
Major Surgical or Invasive Procedure:
None this admission
History of Present Illness:
___ year old female known to the Neurosurgery Service s/p R
right craniotomy parietal mass resection on ___
presenting
to the ED accompanied by her husband with an episode of
expressive aphasia. Per the patient and husband at the bedside,
the patient woke up this morning, and before eating breakfast
patients husband noted that the patient was having difficulty
getting her words out, this lasted approximately 1 hour. ___
services was at the house at this time and recommended to seek
medical attention. It was also noted by the patients husband
that
her blood sugar was low, approx. 80's as he does not recall
exact
number. Patient denies headache, nausea/vomiting. Denies
weakness
or numbness.
Past Medical History:
1. Large cell lung cancer status post resection in ___.
2. COPD.
3. Type 2 diabetes.
4. s/p R right craniotomy parietal mass resection on ___
All:Darvocet-N 100
Social History:
___
Family History:
No family hx heme malignancies. Daughter with ovarian cancer.
Physical Exam:
Upon admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ slug EOMs intact
Neck: Supple.
Head: right parietal incision is clean/dry/intact, no drainage.
mild erythema. sutures/staples removed.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect, agitated.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Upon Discharge:
___: A&Ox3. motor ___. speech is clear, no deficits.
incision is clen/dry/intact, sutures out.
Pertinent Results:
CT HEAD W/O CONTRAST:
1. Status post right parieto-occipital craniotomy and resection
of a right parieto-occipital mass without evidence of new
hemorrhage or mass effect.
2. New small hypodense fluid collection overlying the
craniotomy site.
3. Unchanged small extra-axial hypodense fluid collection
adjacent to the resection bed.
4. Decreased surrounding vasogenic edema.
MRI/MRA w/o CONTRAST: ___
IMPRESSION:
1. Foci of slow diffusion within the right parafalcine parietal
lobe, right cerebellar hemisphere, and possible tiny focus in
the left frontal lobe, with associated T2/FLAIR abnormalities
may be secondary to acute/subacute embolic infarcts.
2. Postsurgical changes status post right parieto-occipital
craniotomy with hemorrhagic products seen within the resection
cavity. Evaluation for residual lesion is limited on this
noncontrast study.
3. No vascular abnormalities identified in the brain or neck.
LENIS: ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CHEST X RAY: ___
IMPRESSION:
In comparison with the study of ___, there is little overall
change.
Again there is enlargement of the cardiac silhouette with
vascular congestion and bilateral pleural effusions with
compressive atelectasis at the bases.
ECHO: ___
IMPRESSION: Normal biventricular cavity sizes and with normal
regional and hyperdynamic global systolic fucntion. Severe
pulmonary artery systolic hypertension. Moderate tricuspid
regurgitation.
Brief Hospital Course:
___ year old female known to the Neurosurgery Service, s/p R
right craniotomy parietal mass resection on ___
presenting with an episode of expressive aphasia. She was
admitted to the neurosurgical service for further workup.
#Aphasia: Patient was neurologically intact while hospitalized
with no episodes of aphasia. Neurology was consulted for
recommendations given the episode of aphasia preceding
admission. An MRI/MRA was completed upon their recommendation
which revealed 3 small infarcts which are unlikely related to
aphasic episode. She was restarted on Aspirin 81 mg. ECHO was
recommended, but may be completed as outpatient. However it was
completed on ___ and showed no clear embolic source, however,
it did show severe pulm HTN compared to previous imaging from
___. She will need to follow up with Cardiology outpatient. She
was continued on Keppra. Final recommendations from neuro stroke
was to start the patient on Lovenox SC ___ hypercoagulable state
___ D-Dimer ___. She was started on Lovenox on ___.
#Hypoxia/Pnemonia: Patient was noted to have a new O2
requirement. Medicine was consulted given CXR concerning for
pneumonia and new O2 requirement with known COPD. She was
started on vancomycin/ceftriaxone/azithromycin for presumed
pneumonia. She was given incentive spirometer and able to wean
to room air. Lower extremity ultrasound was negative for DVT.
Antibiotics were weaned to Levaquin at discharge for a total of
6 days may d/c on ___.
#Hyponatremia: She was hyponatremic to 129 and started on salt
tabs 2g TID, as well as a free water restriction of 750cc.
Improved to 134 at discharge ___. Will need to follow up with
PCP to mon NA levels and wean off sodium tablets.
Medications on Admission:
- keppra 1 gram BID
- glargine 45 units with Humalog correction
- decadron taper, currently on 1mg TID
- folic acid
- allopurinol
- Pepcid
- MV
- NA tabs 1gram BID,
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Do not exceed more than 4 grams.
2. Dexamethasone 1 mg PO Q12H Duration: 24 Hours
Tapered dose - DOWN
RX *dexamethasone 1 mg taper tablet(s) by mouth see taper Disp
#*3 Tablet Refills:*0
3. Dexamethasone 1 mg PO DAILY Duration: 24 Hours
Tapered dose - DOWN
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 80 mg/0.8 mL 0.7 mL twice a day Disp #*60 Syringe
Refills:*0
6. Levofloxacin 750 mg PO DAILY Duration: 6 Days
Stop on ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
7. Sodium Chloride 2 gm PO TID
RX *sodium chloride 1 gram 2 tablet(s) by mouth three times a
day Disp #*60 Tablet Refills:*0
8. Glargine 36 Units Breakfast
Humalog 7 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
9. LevETIRAcetam 1000 mg PO BID
10. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
11. Allopurinol ___ mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Famotidine 20 mg PO BID
___. FoLIC Acid 1 mg PO DAILY
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
16. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Hyponatremia
Hypoglycemia
Embolic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Neurosurgical service for workup after
an episode of aphasia. Neurology and Medicine teams were
consulted.
You were treated for Pneumonia during this admission and for
embolic stroke and hyponatremia.
Followup Instructions:
___
|
10410788-DS-21 | 10,410,788 | 21,085,259 | DS | 21 | 2124-04-03 00:00:00 | 2124-04-03 12:19:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right arm & shoulder pain
Right proximal humerus fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is a ___ year-old woman with a PMH of HTN, HLD s/p
mechanical fall with right arm pain and deformity. There was
positive headstrike with unknown loss of consciousness. CT head
and c-spine were negative. X-rays showed right
proximal humerus fracture. She remembered the fall and denied
syncope. Denied numbness/tingling.
Past Medical History:
HTN
HLD
Anxiety
Insomnia
Depression
Social History:
- Occupation: ___
- Assistive device: none
- Tobacco: denies
- Alcohol: occasional
- Illicits: denies
Physical Exam:
Exam at presentation:
Vitals: T 97.6, P ___, BP 134/93, RR 18, 97% RA
General: Uncomfortable, A&Ox3
Psych: Appropriate mood and affect
HEENT: c-collar in place
Musculoskeletal:
Right Upper Extremity:
skin intact with no abrasions, +ecchymosis
arm held in abduction and external rotation
fires EPL/FPL/FDP/FDS/DIO
sensation intact to light touch in axillary, median, ulnar,
radial distributions
1+ radial pulse, finger tips WWP, cap refill 2 seconds
Left Upper Extremity:
Skin clean - no abrasions, induration, ecchymosis
Arm and forearm compartments soft and compressible
Fires EPL/FPL/FDP/FDS/DIO
Sensation intact to light touch in radial, median, ulnar nerve
istributions
1+ radial pulse
Exam at discharge:
VS: AVSS
GEN: mild distress, ecchymosis & laceration over face & RUE
RUE: very restricted a/pROM secondary to pain, SILT a/m/u/r,
+EPL/FPL/DIO
Pertinent Results:
___ 06:30PM BLOOD WBC-10.9 RBC-4.81 Hgb-13.8 Hct-43.1
MCV-90 MCH-28.7 MCHC-31.9 RDW-14.5 Plt ___
___ 06:30PM BLOOD Neuts-66.1 ___ Monos-4.0 Eos-2.3
Baso-0.6
___ 06:30PM BLOOD Glucose-153* UreaN-19 Creat-0.9 Na-142
K-4.2 Cl-99 HCO3-26 AnGap-21*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right proximal humerus fracture and was admitted to the
orthopedic surgery service primarily for pain control. There
were no indications for surgery at this time. The RUE were
placed in a sling for comfort, and RUE was made non-weight
bearing. The patients home medications were continued throughout
this hospitalization. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, and the patient was
voiding/moving bowels spontaneously. The patient is non
weight-bearing in the right upper extremity. The patient will
follow up in 1 week where Xrays will be taken to evaluate the
fracture. At that time, a decision will be made whether this
fracture will be managed operatively or non-operatively. A
thorough discussion was had with the patient and two daughters
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*60 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
5. Sertraline 200 mg PO DAILY
6. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60
Tablet Refills:*0
9. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*60 Tablet Refills:*0
10. DiphenhydrAMINE 12.5 mg PO Q6H:PRN pruritus
RX *diphenhydramine HCl [Allergy (diphenhydramine)] 25 mg 0.5
(One half) tablet(s) by mouth every six (6) hours Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right proximal humerus fracture
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ACTIVITY AND WEIGHT BEARING:
- Non weight-bearing, right upper extremity
- Sling for comfort
Followup Instructions:
___
|
10410872-DS-7 | 10,410,872 | 29,300,512 | DS | 7 | 2186-03-20 00:00:00 | 2186-03-20 15:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Flagyl / Levaquin / Percocet / Biaxin
Attending: ___.
Chief Complaint:
Nausesa, Vomiting, Diarrhea
Major Surgical or Invasive Procedure:
___ Paraspinal Fluid Drainage: ___ of serosanguinous fluid was drained, no active purulent
drainage or exudative material from the fluid collection.
Specimens sent for bacterial, fungal, and AFB stain/culture. No
post-procedural complications.
History of Present Illness:
___ female with history of hypertension, RA, anxiety,
and chronic pain, s/p anterior lateral fusion of T10-L2 last
month presenting with nausea, vomiting, and diarrhea from rehab.
Patient reports frequent emesis since noon on ___ and was
unable to keep anything down. She is thus unsure if food made
her pain worse. She denies blood in her stools. And the only ABD
pain she had was faint, in the RLQ. Family noted patient to be
diaphoretic. Denies chest pain, shortness of breath, numbness,
weakness, melena, hematochezia, urinary symptoms. Patient
reports having back pain that is stable from surgery.
In the ED, initial vitals were: 98 88 162/99 16 97% RA
- Labs were significant for:WNL CBC and Chem 7, AP 129,
otherwise WNL LFTs, negative UA, normal coags, lactate of 1.7.
and Tnt of 0.06 without chest pain or EKG changes.
- Imaging revealed:
1. Colitis of the sigmoid and descending colon. The etiology of
this could be
infectious, inflammatory or ischemic. No free air or drainable
fluid
collection.
2. 2.7 x 3.8 x 7.5 cm fluid collection in the pleural space
along the left
spinal fixation hardware extending from T8 -T11 with rim
enhancement and
locule of gas. Although it is possible this is postsurgical
seroma, it is
concerning for infection. Consider sampling fluid for
diagnosis.
3. Left lower lobe consolidation suspicious for pneumonia.
4. Large hiatal hernia with tight transition at the
diaphragmatic hiatus.
-Ortho Spine saw in the ED and recommended admission to
medicine; they will see her in the AM with their attending.
- The patient was given Zofran, Vanc/Zosyn, Aspirin for Tnt
bump, Ativan, Reglan, and 2L of fluids.
Upon arrival to the floor, Pt is NAD and without ABD pain,
chest pain, or SOB.
Past Medical History:
DEPRESSION
RHEUMATOID ARTHRITIS
STROKE
SPINAL FUSION
ANXIETY
CHRONIC LOW BACK PAIN
ROTATOR CUFF REPAIR
OSTEOARTHRITIS
SKIN CANCERS
BRAIN HEMORRHAGE
SHORT TERM MEMORY LOSS
DUODENAL ULCER
ANEMIA
MENIERE'S DISEASE
HYPOTHYROIDISM
Social History:
___
Family History:
Mother UTERINE CANCER / Father LUNG CANCER
Physical Exam:
Exam on Admission:
T 98.5, 110-120/60s-80s, 98-104, RR 16 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds
hyperactive, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Exam on Discharge:
T 98.0, 110-120s/___, ___, RR 16 98% RA
General: AAOx3, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB
Abdomen: Soft, NT, ND, +BS, no organomegaly, no rebound or
guarding
GU: No CVA tenderness, No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: L hemineglect and hemianopsia. EOMI, PERRL, ___ strength
upper/lower extremities, grossly normal sensation, mild
hypereflexia on L, gait deferred.
Pertinent Results:
___ 09:50AM GLUCOSE-180* UREA N-7 CREAT-0.6 SODIUM-136
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-21* ANION GAP-21*
___ 09:50AM CK-MB-8 cTropnT-0.09*
___ 09:50AM ALT(SGPT)-17 AST(SGOT)-29 LD(LDH)-359* ALK
PHOS-110* TOT BILI-0.3
___ 09:50AM CK-MB-8 cTropnT-0.09*
___ 09:50AM CK-MB-8 cTropnT-0.09*
___ 09:50AM ALBUMIN-3.7 CALCIUM-9.2 PHOSPHATE-4.1#
MAGNESIUM-1.6
___ 09:50AM WBC-13.4*# RBC-4.37 HGB-12.1 HCT-36.8 MCV-84
MCH-27.7 MCHC-32.9 RDW-21.7* RDWSD-65.1*
___ 09:50AM PLT COUNT-346
___ 09:50AM ___ PTT-30.1 ___
___ 02:10AM ___ COMMENTS-GREEN
___ 02:10AM ___ COMMENTS-GREEN
___ 02:10AM LACTATE-1.7
___ 02:10AM LACTATE-1.7
___ 02:00AM cTropnT-0.12*
___ 09:31PM URINE HOURS-RANDOM
___ 09:31PM URINE HOURS-RANDOM
___ 09:31PM URINE HOURS-RANDOM
___ 09:31PM URINE HOURS-RANDOM
___ 09:31PM URINE HOURS-RANDOM
___ 09:31PM URINE UHOLD-HOLD
___ 09:31PM URINE UHOLD-HOLD
___ 09:31PM URINE GR HOLD-HOLD
___ 09:31PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:48PM ___ PTT-35.3 ___
___ 07:50PM GLUCOSE-162* UREA N-7 CREAT-0.4 SODIUM-137
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-25 ANION GAP-19
___ 07:50PM GLUCOSE-162* UREA N-7 CREAT-0.4 SODIUM-137
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-25 ANION GAP-19
___ 07:50PM estGFR-Using this
___ 07:50PM estGFR-Using this
___ 07:50PM ALT(SGPT)-20 AST(SGOT)-38 CK(CPK)-126 ALK
PHOS-129* TOT BILI-0.3
___ 07:50PM ALT(SGPT)-20 AST(SGOT)-38 CK(CPK)-126 ALK
PHOS-129* TOT BILI-0.3
___ 07:50PM ALBUMIN-4.0
___ 07:50PM NEUTS-81.5* LYMPHS-10.1* MONOS-6.8 EOS-0.3*
BASOS-0.9 IM ___ AbsNeut-6.10 AbsLymp-0.76* AbsMono-0.51
AbsEos-0.02* AbsBaso-0.07
___ 07:50PM PLT COUNT-357
___ 07:50PM NEUTS-81.5* LYMPHS-10.1* MONOS-6.8 EOS-0.3*
BASOS-0.9 IM ___ AbsNeut-6.10 AbsLymp-0.76* AbsMono-0.51
AbsEos-0.02* AbsBaso-0.07
___ 07:50PM WBC-7.5 RBC-4.55 HGB-12.4 HCT-37.9 MCV-83
MCH-27.3 MCHC-32.7 RDW-21.2* RDWSD-62.9*
___ 07:50PM WBC-7.5 RBC-4.55 HGB-12.4 HCT-37.9 MCV-83
MCH-27.3 MCHC-32.7 RDW-21.2* RDWSD-62.9*
___ 07:50PM LACTATE-2.4*
___ 07:50PM LACTATE-2.4*
___ 07:50PM ALBUMIN-4.0
___ 07:50PM ALBUMIN-4.0
___ 07:50PM CK-MB-4 cTropnT-0.06*
___ 07:50PM LIPASE-17
___ 07:50PM ALT(SGPT)-20 AST(SGOT)-38 CK(CPK)-126 ALK
PHOS-129* TOT BILI-0.3
___ 07:50PM estGFR-Using this
___ 07:50PM estGFR-Using this
___ 07:50PM GLUCOSE-162* UREA N-7 CREAT-0.4 SODIUM-137
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-25 ANION GAP-19
___ 08:48PM ___ PTT-35.3 ___
___ 09:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 09:31PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:31PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:31PM URINE GR HOLD-HOLD
___ 09:31PM URINE UHOLD-HOLD
___ 09:31PM URINE HOURS-RANDOM
___ 09:31PM URINE HOURS-RANDOM
___ 09:31PM URINE HOURS-RANDOM
___ 05:20AM BLOOD WBC-6.1 RBC-3.56* Hgb-9.7* Hct-30.9*
MCV-87 MCH-27.2 MCHC-31.4* RDW-20.8* RDWSD-66.4* Plt ___
___ 05:25AM BLOOD WBC-6.9 RBC-3.78* Hgb-10.2* Hct-33.1*
MCV-88 MCH-27.0 MCHC-30.8* RDW-21.6* RDWSD-68.3* Plt ___
___ 05:45AM BLOOD WBC-10.0 RBC-3.43* Hgb-9.5* Hct-30.0*
MCV-88 MCH-27.7 MCHC-31.7* RDW-22.1* RDWSD-70.4* Plt ___
___ 09:50AM BLOOD WBC-13.4*# RBC-4.37 Hgb-12.1 Hct-36.8
MCV-84 MCH-27.7 MCHC-32.9 RDW-21.7* RDWSD-65.1* Plt ___
___ 07:50PM BLOOD WBC-7.5 RBC-4.55 Hgb-12.4 Hct-37.9 MCV-83
MCH-27.3 MCHC-32.7 RDW-21.2* RDWSD-62.9* Plt ___
___ 05:20AM BLOOD Neuts-60.1 Lymphs-18.2* Monos-12.0
Eos-8.4* Baso-0.8 Im ___ AbsNeut-3.66 AbsLymp-1.11*
AbsMono-0.73 AbsEos-0.51 AbsBaso-0.05
___ 05:25AM BLOOD Neuts-72.1* Lymphs-10.5* Monos-9.2
Eos-6.6 Baso-1.0 Im ___ AbsNeut-4.98 AbsLymp-0.73*
AbsMono-0.64 AbsEos-0.46 AbsBaso-0.07
___ 05:20AM BLOOD Plt ___
___ 05:25AM BLOOD Plt ___
___ 05:25AM BLOOD ___ PTT-32.6 ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD PTT-32.4
___ 09:50AM BLOOD Plt ___
___ 09:50AM BLOOD ___ PTT-30.1 ___
___ 08:48PM BLOOD ___ PTT-35.3 ___
___ 07:50PM BLOOD Plt ___
___ 05:20AM BLOOD Glucose-109* UreaN-5* Creat-0.4 Na-140
K-3.4 Cl-103 HCO3-26 AnGap-14
___ 05:25AM BLOOD Glucose-94 UreaN-5* Creat-0.4 Na-142
K-3.9 Cl-105 HCO3-26 AnGap-15
___ 05:45AM BLOOD Glucose-85 UreaN-6 Creat-0.5 Na-140 K-4.0
Cl-105 HCO3-25 AnGap-14
___ 09:50AM BLOOD Glucose-180* UreaN-7 Creat-0.6 Na-136
K-3.2* Cl-97 HCO3-21* AnGap-21*
___ 09:50AM BLOOD ALT-17 AST-29 LD(LDH)-359* AlkPhos-110*
TotBili-0.3
___ 07:50PM BLOOD ALT-20 AST-38 CK(CPK)-126 AlkPhos-129*
TotBili-0.3
___ 09:45AM BLOOD cTropnT-0.03*
___ 09:50AM BLOOD CK-MB-8 cTropnT-0.09*
___ 02:00AM BLOOD cTropnT-0.12*
___ 07:50PM BLOOD CK-MB-4 cTropnT-0.06*
___ 05:20AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.8
___ 05:25AM BLOOD Calcium-8.9 Phos-4.6* Mg-2.0
___ 05:45AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.2
___ 09:50AM BLOOD Albumin-3.7 Calcium-9.2 Phos-4.1# Mg-1.6
___ 07:50PM BLOOD Albumin-4.0
___ 02:10AM BLOOD ___ Comment-GREEN
___ 02:10AM BLOOD Lactate-1.7
___ 07:50PM BLOOD Lactate-2.4*
___: Hip Xray
IMPRESSION:
There is joint space narrowing that is slightly more prominent
than on the
right with mild hypertrophic spurring. Generalized osteopenia
of the bony
structures.
There is opacification of uncertain etiology overlying the lower
spine and
upper sacrum on the frontal view. This could reflect residual
contrast
material from the CT of ___.
CT Procedure Note:
FINDINGS:
A needle was inserted into the left paravertebral fluid
collection however it
was not drainable, likely representing a hematoma. Small small
sample sent
for microbiology. There were no immediate postprocedure
complications.
IMPRESSION:
The left paravertebral body fluid collection was not drainable
likely
representing a hematoma. A small sample was sent for
microbiology evaluation
INDICATION: ___ year old woman with LLL consolidation // ___
year old woman
with LLL consolidation
COMPARISON: ___
FINDINGS:
Interval increase in the retrocardiac and left upper lobe
opacity. There is
also increasing moderate left pleural effusion. The right lung
remains clear.
Mild cardiomegaly. No pneumothorax. Moderate hiatal hernia.
Prior spinal
surgery with hardware along the lower thoracic spine.
Brief Hospital Course:
___ with RA, Anxiety, Chronic pain presenting with N&V found to
have colitis on CT and paraspinal fluid collection.
#Colitis: Etiology is infectious vs ischemic vs inflammatory.
Ischemic and inflammatory less likely given lack of BRBPR, and
absence of acute pain. Colitis of the sigmoid and descending
colon likely infectious, including cdiff colitis given her rehab
home status. We obtained an ID consultation, who recommended
that given her nursing home status combined with high volume
diarrhea, we should empirically treat for Cdiff colitis. We
later discontinued the antibiotics when her Cdiff returned
negative. Additionally, we tested for EBV, CMV which were also
negative. This was thought likely secondary to viral
gastroenteritis.
#Surgical Fluid Collection, paraspinal: large 3cm x4cm x8cm
Concern for infection given gas found on CT and ring enhancing.
We consulted interventional radiology who performed a drainage,
and commented that only ___ ccs of serosanguinous fluid drained,
and that this was likely a residual hematoma from her recent
spinal fusion surgery. The fluid was sent for bacterial, fungal
and AFB culture/stain, which are NGTD at the time of discharge.
#LLL Consolidation: A LLL consolidation was observed on CT,
adjacent to the fluid pocket. Concern for inflammatory process
vs. early PNA from surgical site. No cough, fever, or
leukocytosis rendered PNA less likely. We treated her with
vanc/zosyn for one day, and discontinued it as we felt it was
more likely to be due to adjacent inflammation induced by the
hematoma as opposed to a true infection. Her respiratory
symptoms remained normal throughout the hospital admission.
#Trop elevation: Patient had a mild trop elevation to 0.12,
without EKG changes or symptoms of chest pain/discomfort/SOB. We
subsequently trended her troponin and it decreased to 0.08 and
0.03. This was likely due to demand ischemia in the setting of
severe volume depletion.
#RA: In discussion with Dr. ___ (PCP), we were
recommended to hold methotrexate and orencia during this
hospitalization, which we did. She was asymptomatic throughout
the admission. Given no evidence of infection with above
workup, methotrexate was restarted on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Baclofen 10 mg PO BID
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
4. Docusate Sodium 100 mg PO BID
5. Fentanyl Patch 100 mcg/h TD Q48H
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Gabapentin 800 mg PO TID
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Magnesium Oxide 400 mg PO DAILY
11. modafinil 100 mg oral daily
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 40 mg PO BID
14. Oxybutynin 5 mg PO BID
15. Potassium Chloride 20 mEq PO DAILY
16. QUEtiapine Fumarate 50 mg PO QID
17. Sertraline 100 mg PO DAILY
18. Sucralfate 1 gm PO BID
19. SulfaSALAzine_ 1000 mg PO BID
20. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
21. Senna 8.6 mg PO BID:PRN constipation
22. Boniva (ibandronate) 150 mg oral once per month
23. Ezetimibe 10 mg PO DAILY
24. Hydroxychloroquine Sulfate 200 mg PO BID
25. Ranitidine 300 mg PO QHS
26. Rosuvastatin Calcium 5 mg PO QPM
27. Zolpidem Tartrate 5 mg PO QHS
28. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN
pain
Discharge Medications:
1. Baclofen 10 mg PO BID
2. Ezetimibe 10 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. Omeprazole 40 mg PO BID
5. QUEtiapine Fumarate 50 mg PO QID
6. Ranitidine 300 mg PO QHS
7. Rosuvastatin Calcium 5 mg PO QPM
8. Zolpidem Tartrate 5 mg PO QHS
9. SulfaSALAzine_ 1000 mg PO BID
10. Sucralfate 1 gm PO BID
11. Sertraline 100 mg PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. Levothyroxine Sodium 75 mcg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Acetaminophen 325-650 mg PO Q6H:PRN pain
16. Fentanyl Patch 100 mcg/h TD Q48H
17. Hydroxychloroquine Sulfate 200 mg PO BID
18. Multivitamins 1 TAB PO DAILY
19. Boniva (ibandronate) 150 mg oral once per month
20. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
21. Furosemide 20 mg PO DAILY
22. modafinil 100 mg oral daily
23. Oxybutynin 5 mg PO BID
24. Potassium Chloride 20 mEq PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses: Colitis, hematoma troponin elevation.
Secondary Diagnoses:
DEPRESSION
RHEUMATOID ARTHRITIS
STROKE
SPINAL FUSION
ANXIETY
CHRONIC LOW BACK PAIN
ROTATOR CUFF REPAIR
OSTEOARTHRITIS
SKIN CANCERS
BRAIN HEMORRHAGE
SHORT TERM MEMORY LOSS
DUODENAL ULCER
ANEMIA
MENIERE'S DISEASE
HYPOTHYROIDISM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, you were hospitalized for nausea, vomiting and
diarrhea. While you were here, we worked up the cause of your
symptoms and gave you fluids to replete the volume that you
lost. We performed a CT scan of the abdomen that showed evidence
of colitis and empirically treated you for C. Diff infectious
colitis given your high risk factors of coming from a nursing
home, but discontinued the vancomycin once your C.Diff test
returned negative. The CT abdomen also showed a fluid collection
near the T10-T12 paraspinal space next to the spinal fusion
hardware that had gas and was ring enhancing, which was
concerning for a possible infection. We consulted interventional
radiology who performed a drain and thought it was only a
hematoma as only ___ of blood came out. We sent the specimen
for bacterial and fungal culture analysis, which are pending but
thus far have been negative. There was a left lower lobe
consolidation on the Chest Xray, but it was likely a result of
inflammation from the fluid collection, and not an infection. It
will likely resolve on it's own. Finally, We discussed with your
primary doctor, ___ who recommended holding your
orencia and methotrexate while you are here, which we did. We
scheduled an appointment for you with Dr. ___ in
gastroenterology on ___.
Followup Instructions:
___
|
10410872-DS-8 | 10,410,872 | 29,101,394 | DS | 8 | 2188-02-12 00:00:00 | 2188-02-12 14:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Flagyl / Levaquin / Percocet / Biaxin / Cipro
Attending: ___.
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None during hospital stay
History of Present Illness:
Ms. ___ is a ___ year old female with h/o RA (remicade
then humira now ___), CVA (occipital perm visual loss),
spinal fusion (lumbar and thoracic), anxiety, chronic low back
pain, rotator cuff repair, osteoarthritis, skin cancer, duodenal
ulcer, anemia, Meniere's, hypothyroidism who presents for
hypoxia.
Patient went to pain clinic today and had bilateral SI joint
injection and trigger point injections as an outpatient. Home
medications include fentanyl patch 125mcg/hr, dilaudid 4mg q4-6
hr PRN, clonazepam 0.5mg BID PRN, baclofen 20mg TID, gabapentin
800mg qid, ambien 5mg qhs and provigil. Patient pretreated
herself with clonazepam prior to procedure (around ___ pm),
unsure if taken in conjunction with dilaudid. She was sedated
following the procedure and required O2 for desat to low ___.
Patient did not inform providers prior to or during procedure
that she had taken additional anxiolytics. Patient reports a lot
of stress with moving and packing. She also reports has been in
horrible pain and barely sleeping, and feels that this is why
she has been so tired. Her pain is mostly centered on her right
flank, secondary to spinal surgery she had ___ years ago. In
the hospital in the past, she has intermittently worn oxygen but
never at home. Her baseline O2 is around 93-94. Reports left
pain clinic around 6pm in ambulance to come here. Reports has
been sleeping in and out in triage. She denies fever, chills,
chest pain, cough, n/v/d, SOB, unilateral leg swelling. Reports
some b/l leg swelling.
In the ED, initial vitals were 98.3 46 135/52 18 95% Nasal
Cannula. Labs showed WBC 3.5K, d-dimer 539, urine positive for
opiates. CTA chest showed no pulmonary embolism, but study
limited by motion.
Currently, the patient does not report feeling short of breath
and does not have any cough. She does not feel confused. She
reports that she often gets very tired when she has pain
episodes, and she had been having one the last few days. There
is no chest pain.
Review of systems: 10 pt ROS negative other than noted
Past Medical History:
Rheumatoid arthritis
Depression
Hypothyroidism
s/p CVA
s/p Brain hemorrhage
s/p Spinal fusion
Anxiety
Chronic low back pain
s/p Rotator cuff repair
Osteoarthritis
Skin cancer
Duodenal ulcer
Anemia
Meniere's disease
Social History:
___
Family History:
Mother UTERINE CANCER / Father LUNG CANCER
Physical Exam:
PHYSICAL EXAM on ADMISSION:
Vitals: 98.0PO 135/53 48 16 96 2L NC
GEN: Alert, oriented to name and situation, not place. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, mildly tender in left abdomen, non-distended, + bowel
sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: non-focal.
PSYCH: Appropriate and calm
PHYSICAL EXAM on DISCHARGE:
Vitals: 98.0 115/74 53 16 100 RA
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
HENT: NCAT, MMM, OP clear, hearing adequate
Cardiovasc: RRR, no obvious MRG. Full pulses, no edema.
Resp: normal effort, breathing unlabored, no accessory muscle
use, lungs CTA ___ without adventitious sounds.
GI: Soft, NT, ND, BS+. No HSM.
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect. Thought linear.
GU: No foley
Pertinent Results:
Labs on admission:
___ 09:06PM BLOOD WBC-3.5* RBC-4.02 Hgb-11.6 Hct-37.0
MCV-92 MCH-28.9 MCHC-31.4* RDW-15.3 RDWSD-51.8* Plt ___
___ 09:00PM BLOOD Glucose-150* UreaN-10 Creat-0.6 Na-142
K-4.2 Cl-100 HCO3-26 AnGap-16
___ 09:00PM BLOOD cTropnT-<0.01
___ 09:00PM BLOOD D-Dimer-539*
___ 09:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Labs on discharge:
___ 06:43AM BLOOD WBC-4.4 RBC-3.81* Hgb-11.4 Hct-35.9
MCV-94 MCH-29.9 MCHC-31.8* RDW-15.8* RDWSD-53.6* Plt ___
___ 06:43AM BLOOD Glucose-103* UreaN-10 Creat-0.5 Na-141
K-4.3 Cl-101 HCO3-27 AnGap-13
Imaging on admission:
CXR
No acute cardiopulmonary process.
CTA Chest
1. Study partially limited by motion. No evidence pulmonary
embolus detected to the segmental level only and no acute aortic
abnormality.
2. Large hiatal hernia.
3. Left lower lobe atelectasis.
4. No CT evidence for interstitial lung disease.
Brief Hospital Course:
This is a ___ with h/o RA, CVA (occipital perm visual loss),
spinal fusion (lumbar
and thoracic), anxiety, chronic low back pain, rotator cuff
repair, osteoarthritis, skin cancer, duodenal ulcer, anemia,
Meniere's, hypothyroidism, significant polypharmacy with
multiple CNS depressing medications, who presented with lethargy
and bland hypoxemia.
# Lethargy and
# Acute hypoxic respiratory failure due to
# Atelectasis and reduced ventilator drive due to
# Polypharmacy, specifically Klonopin interaction with home
analgesic regimen
# Possible OSA: She was referred to the ED from the
post-procedure area for lethargy and hypoxia. She was stabilized
on 2L NC, monitored overnight, and slowly cleared. Oxygen was
fully weaned off in the morning and with ambulation she was >97%
on RA. She did drop to the mid-high-80s during a nap later in
the morning, but upon being awoken she promptly improved to
>95%RA. Workup was unremarkable but for mild atelectasis on
imaging (trop negative, CTA negative for PE within limitation of
movement artifact, no infiltrates on CXR or CT, no symptoms of
cardiothoracic process). She reportedly took Klonopin prior to
the procedure, and may have taken an extra dose of her Dilaudid.
It was thought that this was the likely cause of her lethargy,
and probably promoted a reduced respiratory drive leading to
hypoxemia. It is also quite possible that she has some
underlying OSA, given the drop in her oxygen level during her
mid-morning nap.
- She was counseled extensively about polypharmacy and dangers
of CNS depressing medications, especially combination of
benzodiazepines with opiates
- I told her to avoid all benzodiazepines and
benzodiazepine-like agents and marked these as discontinued on
her med list
- PCP followup scheduled prior to discharge to discuss
hospitalization and medication tapering, consider referral for
sleep study
- Rheumatology follow scheduled prior to discharge to discuss
hospitalization and medication tapering
- Consider referral for outpatient sleep study
# Bradycardia: Mild, asymptomatic. Likely due to sedative drug
use.
# Prolonged QT interval: On multiple QT-prolonging agents. She
was encouraged to limit polypharmacy.
# Rheumatoid arthritis
# Chronic pain: As above, significant polypharmacy with multiple
analgesics.
- I encouraged her to follow up with her PCP and rheumatologist
and wean pain medications as much as able, to minimize side
effects
# Depression/anxiety: Continued home sertraline. Discontinued
Klonopin as above.
# Hypothyroidism: Continued home levothyroxine.
Plan discussed with her and her husband. All questions were
answered. They were both amenable to plan. >30 minutes spent
coordinating discharge home.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 800 mg PO QID
2. Omeprazole 40 mg PO BID
3. Ranitidine 300 mg PO QHS
4. Rosuvastatin Calcium 5 mg PO QPM
5. Zolpidem Tartrate 2.5-5 mg PO QHS
6. SulfaSALAzine_ 500 mg PO DAILY
7. Sucralfate 1 gm PO BID
8. Sertraline 200 mg PO DAILY
9. Levothyroxine Sodium 75 mcg PO DAILY
10. FoLIC Acid 2 mg PO DAILY
11. Acetaminophen 1000 mg PO Q6H:PRN pain
12. Hydroxychloroquine Sulfate 200 mg PO DAILY
13. Furosemide 20 mg PO DAILY
14. modafinil 100 mg oral daily
15. Oxybutynin 5 mg PO BID
16. Magnesium Oxide 400 mg PO DAILY
17. Baclofen 20 mg PO TID
18. ClonazePAM 0.5 mg PO BID:PRN anxiety
19. diclofenac sodium 1 % topical BID
20. Fentanyl Patch 50 mcg/h TD Q48H
21. HYDROmorphone (Dilaudid) 4 mg IV Q6H:PRN Pain - Moderate
22. Linzess (linaclotide) 145-290 mg oral DAILY
23. Methotrexate 0.7 mL IM WEEKLY
24. Movantik (naloxegol) 25 mg oral DAILY
25. Simethicone 80 mg PO TID:PRN indigestion
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Baclofen 20 mg PO TID
Consider tapering/stopping this; can cause sleepiness and other
side effects
3. diclofenac sodium 1 % topical BID
4. Fentanyl Patch 50 mcg/h TD Q48H
Consider tapering/stopping this; can cause sleepiness and other
side effects
5. FoLIC Acid 2 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Gabapentin 800 mg PO QID
Consider tapering/stopping this; can cause sleepiness and other
side effects
8. HYDROmorphone (Dilaudid) 4 mg IV Q6H:PRN Pain - Moderate
Consider tapering/stopping this; can cause sleepiness and other
side effects
9. Hydroxychloroquine Sulfate 200 mg PO DAILY
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Magnesium Oxide 400 mg PO DAILY
12. Methotrexate 0.7 mL IM WEEKLY
13. modafinil 100 mg oral daily
14. Movantik (naloxegol) 25 mg oral DAILY
15. Omeprazole 40 mg PO BID
16. Oxybutynin 5 mg PO BID
Consider tapering/stopping this; can cause sleepiness and other
side effects
17. Ranitidine 300 mg PO QHS
18. Rosuvastatin Calcium 5 mg PO QPM
19. Sertraline 200 mg PO DAILY
20. Simethicone 80 mg PO TID:PRN indigestion
21. Sucralfate 1 gm PO BID
22. SulfaSALAzine_ 500 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute hypoxic respiratory failure
Atelectasis
Adverse effect of pain and anxiety medication
Chronic pain on multiple pain medications
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with low oxygen levels and sleepiness. Your
workup was largely unremarkable and you improved with time. By
the morning, you were breathing well and your oxygen level was
normal without any extra oxygen.
It was thought that the most likely cause of this low oxygen
level and sleepiness is mild collapsing of the lungs and failing
to take deep breaths around the time of your procedure, which
was exacerbated by the use of Klonopin on the background of your
multiple other pain medications.
You may be using too many pain medications at too high of a
dose, which could be causing side effects such as slowing of
thought, sleepiness, and reduced drive to breath and inflate the
lungs.
As a first step, you should avoid taking any additional Klonopin
or similar medications (like Ativan, Serax, Valium, Librium), as
they interact negatively with the pain medications you take.
Next, you should talk with your PCP and your ___
about changing your pain medication regimen. You may require a
taper of pain medication, or a change of pain medication, in
order to limit side effects. Your PCP may want to refer you for
a sleep study to make sure you do not have sleep apnea, which is
a medical condition that can make problems like this more
likely.
Please do not drive or operate machinery while taking
medications that can cause side effects like these. Please
exercise extreme caution with making important life or financial
decisions while under the influence of strong pain medications.
Followup Instructions:
___
|
10410881-DS-23 | 10,410,881 | 28,242,567 | DS | 23 | 2164-10-23 00:00:00 | 2164-10-23 23:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine Containing Agents Classifier
Attending: ___.
Chief Complaint:
diarrhea, failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with metastatic renal cell
carcinoma with lung, bone and CNS involvement s/p L frontal mass
resection + cavity SRS having progressed through pazopanib and
now on his ___ cycle of nivolumab who presents with poor oral
intake, nausea and diarrhea.
He completed XRT to C-spine the week of ___. After
which, he had esophagitis resulting in poor oral intake. For the
past week the patient has had poor appetite. This has been
associated with nausea, dry heaves, and loose stools. He has
been
able to drink some liquids but has had minimal solid food
intake.
His nausea improved over the weekend but he has continued having
large loose bowel movements once to twice daily without fecal
urgency or abdominal pain. He additionally complains of fatigue
and unsteadiness upon standing.
ED initial vitals were 98.5 100 138/83 18 99% RA
Prior to transfer vitals were 98.3 90 100/66 17 99% RA
Exam in the ED showed : "Cachectic, frail, no abdominal
tenderness"
ED work-up significant for:
-CBC: 7.6 > 9.5 < 434
-Chemistry: 128->1277/4.8 | ___ | ___
13.1 -> 10.7| 1.8 | 2.7
-Lactate: 2.6->1.7
-Coags: INR 1.4 | 26.2
-LFTs: ___ | 85/0.5
-CXR: no acute process
ED management significant for:
-Medications: 1L NS, 75cc/h ___ NS
On arrival to the floor, patient reports feeling slightly less
fatigued after fluids. No longer feels unsteady.
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, weakness/numbnesss,
shortness
of breath, cough, hemoptysis, chest pain, palpitations,
abdominal
pain, hematemesis, hematochezia/melena, dysuria, hematuria, and
new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: Found to have a 10cm mass in lower pole of left
kidney
on abdominal U/S after presenting with abdominal discomfort.
- ___: CT A/P showed that the left renal vein was patent,
and
the right kidney contained a sub-centimeter cyst, with
enhancement, suspicious for a second tumor.
- ___: He underwent left-sided nephrectomy at the ___
___
___ by Dr. ___. He developed mild Cr rise post
nephrectomy, was evaluated by nephrology and felt to be due
solitary kidney, he was placed on ACE-I.
- He has otherwise largely been well until ___ at which time
he presented to PCP with few weeks of L groin pain.
- ___: underwent CT that showed multiple bilateral new
pulmonary nodules, 9.3 cm R adrenal mass, and 4.4cm L iliac
metastasis.
- ___: adrenal mass c/w metastatic RCC
- ___: Staging brain MRI showed L frontal mass
- ___: he underwent resection by Dr ___. Biopsy also
c/w
metastatic RCC
- ___: Completed palliative SRS to L hip (3000Gy)
and
adjuvant SRS to L frontal resection cavity (25Gy)
- ___: Underwent left total hemiarthroplasty by Dr. ___
___. Post-op course was complicated by GI bleeding
requiring total of 8 U PRBCs. EGD showed multiple ulcers,
gastric lesion
w/ visible vessel was cauterized. Steroids were tapered and he
was
continued on PPI.
- ___: repeat EGD showed resolution of ulcer
- ___: completed SRS to calavarial vertex lesion
- ___: started pazopanib 400mg daily
- ___: increased pazopanib to 400 alternating with 600mg
- ___: increased pazopanib to 600mg daily
- ___: Restaging scans with mixed response
- ___: MRI shoulder with new bone lesion and MRI brain with
2
new brain mets in cerebellum and parietal area
- ___: stop pazopanib. C1D1 nivolumab
PAST MEDICAL HISTORY:
1. Hypertension
2. Solitary kidney secondary to left-sided nephrectomy in ___
___ at the ___ by Dr. ___
renal cell carcinoma. This was discovered after a CT scan done
for epigastric pain revealed a renal mass.
3. Hyperhomocysteinemia for the past six months
4. Hypertriglyceridemia.
5. Sigmoid diverticulosis.
6. s/p appendectomy ___
Social History:
___
Family History:
Significant for hypertension. There is no family
history of diabetes. His father and mother both had skin cancer.
There is no history of heart disease. There is no history of
renal cell carcinoma. There is no history of renal disease or
autoimmune disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 0006 Temp: 98.2 PO BP: 108/74 HR: 79 RR: 18 O2 sat:
98% O2 delivery: Ra
GENERAL: Frail and cachectic appearing gentleman, in no distress
lying in bed comfortably.
HEENT: Anicteric, PERLL, Mucous membranes dry, oropharynx clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to
light touch intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
VS: ___.___
GENERAL: Frail and cachectic appearing gentleman, in no distress
lying in bed comfortably.
HEENT: Anicteric, PERLL, Mucous membranes dry, oropharynx clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to
light touch intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
=============
___ 02:13PM BLOOD WBC-8.8 RBC-3.69* Hgb-9.6* Hct-29.8*
MCV-81*# MCH-26.0 MCHC-32.2 RDW-14.4 RDWSD-42.1 Plt ___
___ 02:13PM BLOOD Neuts-72.6* Lymphs-14.4* Monos-11.9
Eos-0.2* Baso-0.6 Im ___ AbsNeut-6.37* AbsLymp-1.26
AbsMono-1.04* AbsEos-0.02* AbsBaso-0.05
___ 02:13PM BLOOD Plt ___
___ 02:13PM BLOOD UreaN-15 Creat-0.9 Na-129* K-4.9 Cl-91*
HCO3-25 AnGap-13
___ 02:13PM BLOOD ALT-14 AST-15 AlkPhos-80 TotBili-0.4
___ 02:13PM BLOOD Albumin-4.0 Phos-2.5* Mg-1.9 Iron-26*
___:13PM BLOOD VitB12-456 ___ Ferritn-1386*
DISCHARGE LABS
==============
___ 05:15PM BLOOD WBC-5.6 RBC-3.03* Hgb-8.0* Hct-24.4*
MCV-81* MCH-26.4 MCHC-32.8 RDW-14.3 RDWSD-41.8 Plt ___
___ 05:15PM BLOOD Neuts-70.1 Lymphs-18.1* Monos-10.7
Eos-0.2* Baso-0.4 Im ___ AbsNeut-3.94 AbsLymp-1.02*
AbsMono-0.60 AbsEos-0.01* AbsBaso-0.02
___ 06:39AM BLOOD Glucose-92 UreaN-6 Creat-0.6 Na-137 K-4.3
Cl-105 HCO3-19* AnGap-13
___ 06:39AM BLOOD ALT-8 AST-11 AlkPhos-58 TotBili-0.2
___ 06:39AM BLOOD Calcium-9.7 Phos-2.9 Mg-1.8
MICRO
=====
___ 2:13 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING
=======
___ Abd KUB
There is minimal fecal content in the large bowel.
There is no evidence of bowel obstruction or ileus.
___ CT Abd/Pelvis w/o contrast
1. Small free and intramuscular left iliacus hematoma in the
region of the
known left acetabular metastatic disease.
2. Findings of worsening metastatic disease as noted above.
3. Overall stable appearance of the known right gluteal soft
tissue mass and
multiple renal masses, suboptimally evaluated on this
noncontrast exam.
Brief Hospital Course:
Brief hospital course
======================
Mr. ___ is a ___ year-old gentleman with metastatic renal cell
carcinoma with lung, bone and CNS involvement s/p L frontal mass
resection + cavity SRS having progressed through pazopanib and
now on his ___ cycle of nivolumab who presents with poor oral
intake, nausea and diarrhea. Patient was not found to have any
episode of diarrhea after his admission. He was seen by
nutrition who recommended starting an appetite stimulant
(dronabinol). Patient was found to be hypercalcemic and received
1 dose of pamidronate as well as fluids, with good resolution of
hypercalcemia. Patient was found to have a 2 point drop in his
hemoglobin believed to be dilutional. He received 1 unit of
blood with adequate bump in his hemoglobin. He was also
evaluated with CT of the abdomen and pelvis which showed a small
hematoma in his iliac crests likely due to bleeding metastasis
in his acetabulum, however not contributing to any further
hemoglobin drop. He was started on an iron pill.
#Diarrhea: Patient reported one episode of diarrhea per day
since the ___ prior to admission, however he did not have
any bowel movement during his 2 day admission. Also, patient was
on his ___ month of nivolumab. Enteritis/colitis ___ nivolumab
was considered, however given that diarrhea only occured once a
day this was thought to be unlikely. We obtain an abdominal
x-ray which showed that patient had no constipation, so diarrhea
around constipation became less likely. This problem resolved
while patient was in the hospital.
#Hypercalcemia: Patient was found to have Ca ___ on arrival.
Hypercalcemia improved with fluids. Likely related to bone
metastatic involvement. Patient received 1 dose of pamidronate
while inpatient. Calcium at discharge was 9.7.
#Anemia - patient was found to have a drop in Hgb 9.5 -> 7.5 ->
6.7. He
denies any melena or hemoptysis. He denies any back pain, and
there are no bruises noted on his physical exam. Etiology could
be dilutional effect (given that all lines are down and patient
received ~2L fluids) versus hemolysis versus iron deficiency
anemia versus acute bleeding. Hemolysis was ruled out with
negative hemolysis labs. Iron studies consistent with picture of
iron deficiency anemia combined with anemia of chronic disease.
Patient received 1 unit of blood with appropriate bump in his
hemoglobin. Patient was started on iron pills with Colace at
discharge. Retroperitoneal hematoma was considered in the CT of
the abdomen and pelvis was obtained. Study showed small free and
intramuscular left iliacus hematoma in the region of the known
left acetabular metastatic disease. This found hematoma is
unlikely to have caused a drop in hemoglobin and is likely
related to bleeding of one of his bone metastases.
#Poor oral intake
#Weakness
#Failure to thrive
Likely multifactorial including cancer cachexia and recent
radiation esophagitis. Given current treatment with nivolumab,
adrenalitis and hypothyroidism should be considered. Cortisol
and TSH studies were normal. Nutrition was consulted and they
recommended starting an appetite stimulant. Patient was started
on dronabinol.
#Volume depletion
#Hyponatremia
Clearly volume down on exam, had elevated lactate on arrival
that improved with 1L NS bolus. Given hypovolemia on exam,
hyponatremia is most likely hypovolemic. Urine lytes ___ Na
indicating that patient is Na avid and his hyponatremia may be
due to hypovolemia. Sodium improved with fluids and was 137 at
discharge.
#Metastatic renal cell carcinoma: Has had mixed response to XRT
and nivolumab. Will follow up with Dr. ___ on ___.
#Cancer-associated pain, chronic: Continued home oxycodone 5mg
qid prn
#Hypertension: Lisinopril was held in the setting of dehydration
but was also held at discharge.
#Seizure prophylaxis: Continued on LevETIRAcetam 500 mg PO Q12H.
Transitional issues
===================
[] Calcium at discharge was 9.7. Patient received 1 dose of
pamidronate. He did not have a good response to zoledronic acid
as an outpatient. Consider denosumab as an outpatient.
[] Patient was started on dronabinol for appetite stimulation
[] Patient was started on iron pills with accompanying Colace,
consider IV iron outpatient.
[] Patient had a CT of his abdomen and pelvis showing small free
and intramuscular left iliacus hematoma in the region of the
known left acetabular metastatic disease and findings of
worsening metastatic disease. This has to be followed up by his
outpatient oncologist.
[] Patient has an appointment with Dr. ___ on ___,
___ and an appointment with his orthopedic oncologist on
___
[] Patient received 1 unit of blood with appropriate bump in his
hemoglobin
[] Hemoglobin at discharge was 8, will need follow up CBC at
next hematology appointment
[] lisinopril was held on discharge since blood pressures still
normal/low, follow up outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO BID:PRN Pain - Mild
2. Allopurinol ___ mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
5. Fish Oil (Omega 3) 3600 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. LevETIRAcetam 500 mg PO Q12H
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. Dronabinol 2.5 mg PO BID
RX *dronabinol 2.5 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
5. Acetaminophen 500 mg PO BID:PRN Pain - Mild
6. Allopurinol ___ mg PO DAILY
7. Fish Oil (Omega 3) 3600 mg PO DAILY
8. LevETIRAcetam 500 mg PO Q12H
9. Omeprazole 20 mg PO DAILY
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
11. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until your doctor tells you to
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Diarrhea
Hypercalcemia
Anemia
Failure to thrive
Hyponatremia
Metastatic renal cell carcinoma
Secondary diagnosis
Hypertension
Seizure prophylaxis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
You were admitted due to concern for your poor oral intake,
nausea, and diarrhea.
WHAT HAPPENED IN THE HOSPITAL?
You were seen by our colleagues from nutrition who recommended
starting an appetite stimulant called dronabinol. We gave you a
unit of blood and started you on an iron pill. We obtained an
image of your abdomen which did not show you were constipated.
Your Calcium was also high and you received a special medication
(pamidronate) to lower it. Since your blood counts were dropping
we also obtained an image of your pelvis which showed a small
blood collection in your groin area close to the left femur
head. We think the lower blood counts were due to dilution of
your blood due to all the fluids you received, and not to the
blood collection you had in your groin.
WHAT SHOULD YOU DO AT HOME?
You need to follow-up with your primary oncologist next
___ in clinic. At that time your final read of the CT of
your abdomen will be available. You needs to continue improving
your nutrition so you can keep up with her body needs. Your
lisinopril was held at discharge because of your borderline low
blood pressure and you should not take it until your followup
appointments.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10410935-DS-21 | 10,410,935 | 21,171,601 | DS | 21 | 2116-10-24 00:00:00 | 2116-10-24 15:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with HCV and EtOH Cirrrhosis with decompensation in the form
of portal HTN with ascites, splenomegaly, thrombocytopenia,
coagulopathy, GI bleeding, controlled encephalopathy, and
multifocal HCC who presents from his SNF due to jaundice and
abnormal labs.
Patient had been started ___ on palliative Sorafenib by
heme/onc for his HCC. His skilled nursing facility has kept in
close touch with his providers, and on ___ the RN called from
___ to report patient's skin looked more yellow.
Instructions were to hold Sorafenib and check labs, which came
back notable for T. Bili up to 10.6, AST 167, ALT 93, ALP 148
and Cr 1.1.
Over the past 3 days, patient and his partner/HCP have noticed
overt jaundice with associated fatigure and malaise, so decided
to come in for evaluation.
Patient also reports significant diarrhea recently, up to 10
stools a day, which the patient reports times out around the
time he started sorafenib but also with perhaps a recent
uptitration of his lactulose. He also reports he has been
urinating less and darker in color over the past few days.
Neither patient nor his HCP (who visits him every day) believe
his mental status is off baseline.
In the ED, initial vitals were 98.3 80 131/78 18 98% RA.
Labs notable for Tbili 16.8 from baseline 2.0, INR 1.6 from
baseline 1.2, Cr 2.2 from baseline 0.9. UA with 15WBC, few
bacteria, small Leuk. Blood cultures were drawn.
RUQ U/S With dopplers showed no new thrombi (has old right PV
thrombus, small ascites.
He was ordered for 500mL NS bolus (received the full liter by
time of arrival to floor). Hepatology was consulted. He was also
given 25g/500mL of 5% albumin.
On arrival to the floor, the patient feels comfortable but
reports he is very thirsty. He still is having diarrhea.
Past Medical History:
HCC (see history above), ongoing, s/p three courses
of TACE as well as RFA (see below for detailed history)
-HCV and alcholic cirrhosis complicated by
thrombocytopenia/coagulopathy, ascites, hepatic encephalopathy,
UGIB and LGIB (in ___, PV thrombus concerning for tumor
thrombus
-Hypothyroidism
-Seizures, last in ___
-H/O illicit drug use (crack)
-Tobacco abuse, ongoing
-MVC in ___ with a left hip and left knee fracture
- gait instability attributed to dilantin
Social History:
___
Family History:
His father died of liver cancer in his ___.
Physical Exam:
ON ADMISSION
=============
VS 97.9 | 134/72 | 85 | 20 | 96%RA
General: Somnolent appearing gentleman, does not engage much,
poor eye contact, is in no acute distress.
HEENT: EOMI, PERRLA, marked scleral icterus, conjunctival
pallor, dry oral mucosa, clear oropharynx.
Neck: Supple, no thyromegaly, no carotid bruits, no
lymphadenopathy
CV: RRR, no murmurs/rubs/gallops
Lungs: Adequate chest wall expansion/respiratory effort, distant
breath sounds, clear on auscultation bilaterally
Abdomen: Protuberant, no collateral circulation, fluid wave +,
no ___ dullness on percussion, soft, non-tender.
GU: No CVA tenderness
Extremities: WWP, marked muscular atrophy, good ___ pulses
bilaterally, no pitting edema.
Neuro: Mild somnolence, poorly engaged in encounter. Does follow
commands. Slow speech with verbal pauses. Alert and oriented.
Cannot do serial 7s, serial 1s or basic addition/substraction.
___ motor strength on all 4 extremities. Some weakness weakness
on torso.
ON DISCHARGE
============
VS 98.6 | 131/62 | 88 | 18 | 94%
General: Quite jaundiced, sitting in bed comfortably, in no
acute distress
HEENT: scleral icterus
Neck: Supple
CV: RRR, no murmurs/rubs/gallops
Lungs: distant breath sounds, some scattered ronchi and crackles
Abdomen: NABS Soft, distended, Nontender to palpation
Extremities: WWP, trace edema
Neuro: AOX3 Slow speech with verbal pauses. No asterixis
Labs: Please see below
Pertinent Results:
ADMISSION LABS
===============
___ 06:30PM BLOOD WBC-6.5 RBC-4.18* Hgb-13.0* Hct-41.4
MCV-99* MCH-31.1 MCHC-31.4 RDW-18.1* Plt Ct-83*
___ 06:30PM BLOOD Neuts-74.5* Lymphs-13.6* Monos-8.8
Eos-2.4 Baso-0.7
___ 06:30PM BLOOD ___ PTT-46.9* ___
___ 06:30PM BLOOD Glucose-92 UreaN-35* Creat-2.2*# Na-136
K-4.4 Cl-109* HCO3-19* AnGap-12
___ 06:30PM BLOOD ALT-75* AST-154* AlkPhos-158*
TotBili-16.8*
___ 06:30PM BLOOD Albumin-2.5*
___ 09:00PM URINE Color-AMBER Appear-Hazy Sp ___
___ 09:00PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-6.0 Leuks-SM
___ 09:00PM URINE RBC-16* WBC-15* Bacteri-FEW Yeast-NONE
Epi-0
___ 09:00PM URINE CastHy-11*
___ 09:00PM URINE Mucous-RARE
___ 09:00PM URINE Hours-RANDOM UreaN-727 Creat-203 Na-20
K-50 Cl-43
___ 09:00PM URINE Osmolal-538
DISCHARGE LABS
==============
___ 04:55AM BLOOD WBC-3.0* RBC-2.66* Hgb-8.8* Hct-27.1*
MCV-102* MCH-33.1* MCHC-32.6 RDW-19.3* Plt Ct-60*
___ 05:45AM BLOOD Neuts-65.0 ___ Monos-11.1*
Eos-1.9 Baso-1.0
___ 04:55AM BLOOD ___ PTT-82.8* ___
___ 04:55AM BLOOD Glucose-104* UreaN-31* Creat-1.8* Na-140
K-3.9 Cl-106 HCO3-22 AnGap-16
___ 04:55AM BLOOD ALT-43* AST-101* AlkPhos-63 TotBili-28.3*
___ 04:55AM BLOOD Calcium-8.9 Phos-2.2* Mg-3.0*
RELEVANT TRENDS
================
Total Bilirubin
___ 04:55 28.3*
___ 05:45 26.5*
___ 08:47 29.2*
___ 05:45 25.5*
___ 05:10 27.0*
___ 05:35 25.6*
___ 05:35 25.6*
___ 05:55 26.7*
___ 06:15 26.2*
___ 04:30 22.8*
___ 05:15 21.4*
___ 05:45 18.2*
___ 05:35 17.2*
___ 06:30 15.6*
___ 18:30 16.8*
___ 11:20 1.8*
___ 10:50 1.0
IMAGING
========
LIVER OR GALLBLADDER US (SINGLE ORGAN)Study Date of ___
9:01 ___
IMPRESSION:
1. Cirrhotic heterogeneous liver. The heterogeneity makes
evaluation for
focal mass difficult. If further evaluation for worsening of
the
hepatocellular carcinomas is desired, an MRI of the abdomen is
recommended.
2. Right portal vein is not visualized, likely due to the known
thrombosis in the right portal vein. Reversal of flow in the
main portal vein. Normal
direction of flow in the left portal vein.
3. Patent hepatic veins and hepatic arteries.
4. Cholelithiasis and gallbladder sludge. Mild wall edema is
likely related to the patient's known underlying hepatic
disease.
5. Small amount of ascites.
6. Splenomegaly.
CHEST (PA & LAT)Study Date of ___ 9:44 ___
No acute cardiopulmonary process. Right lower lobe calcified
granuloma, better seen on prior CT.
MRCP (MR ___ Date of ___ 5:21 ___
1. Interval enlargement of a portal venous tumor thrombus, now
encompassing
the right anterior branches, and confluent tumor throughout
segments VI and
IVb, overall progressed since ___. New segment VI
2.2 cm mass
causing inferior displacement of the right adrenal gland.
3. Moderate splenomegaly, parasplenic varices and recanalized
paraumbilical
vein denoting chronic portal hypertension.
4. Mild right posterior and left intrahepatic bile duct
dilation is new since
the prior examination. Cholelithiasis. No ductal stones.
CHEST (PORTABLE AP) Study Date of ___ 11:06 AM
As compared to the previous radiograph, the patient has
developed
mild fluid overload. This is reflected by basoapical blood flow
re-distribution. No evidence of pneumonia. No pleural
effusions. No
substantial atelectasis.
MICROBIOLOGY
=============
___ 7:30 pm STOOL CONSISTENCY: NOT APPLICABLE
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
___ URINE Site: NOT SPECIFIED ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 11:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
___ w/ HCV/EthOH cirrhosis c/b multifocal HCC and PSE presents
with diarrhea, confusion and worsening jaundice. Sorafenib was
held and diarrhea improved. His bilirubin trended up and
plateaued between ___. Once lactulose was uptitrated the
patient's mental status quickly cleared. He was found to have
urinary infection for which he received a course of 5 days of
ceftriaxone. An MRI was done finding tumoral thrombi in two
portal venous system vessels and non-intervenable intrahepatic
biliary duct dilation. Given the extension of his HCC, the
complications and poor response to treatment medical oncology
and radiation oncology considered that any further intervention
would be ineffective and harmful. He is not a transplant
candidate due to his extensive neoplastic involvement. During
the admission he developped progressive renal failure that did
not respond to 1g/kg albumin 25% challenge x3, his renal failure
is likely related to hepato-renal syndrome but since pt not a
transplant candidate would not benefit from midodrine/octreotide
bridging therapy. He subsequently developped volume overload
with pulmonary edema and was diuresed gently with furosemide
40mg IV. HCP requested transfer to ___ which was not
medically indicated but if accepting MD was identified with HCP
primary team would facilitate transfer. After discussion with
patient with palliative care involved, pt was made DNR/DNI based
on his desire of not receiving harmful treatment as outlined in
___ policy ___-36. His MELD on discharge is 34 associated with
a 75.8% 3 month mortality.
TRANSITIONAL ISSUES
===================
#JAUNDICE/ITCH: Patient started on ursodiol 250mg tid as a
palliative measure for jaundice and itch.
#ENCEPHALOPATHY: Receiving lactulose 30mL tid titrated to ___
per day, if worsening encephalopathy can uptitrate frequency or
dosage balancing the discomfort of diarrhea with the discomfort
of confusion.
#SHORTNESS OF BREATH: As renal failure worsens he may develop
further fluid overload that may responde to furosemide 40mg IV
prn, if he becomes refractory to this liquid morphine would be
an option to alleviate the shortness of breath
#PAIN: He has not had any pain during the admission but he could
develop pain as his liver failure worsens and tumoral burden
continues to increase. Liquid morphine would be the ideal pain
control medication for him.
#IF ANY DECOMPENSATION/CONCERN FOR ADMISSION: please page Dr.
___ (___) from ___ to assess whether pt would
benefit from being in the hospital.
#LABORATORY TESTS: He does not need any laboratory follow-up.
#CODE STATUS: DNR/DNI, no ICU care indicated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 750 mg PO BID
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Spironolactone 100 mg PO DAILY
6. Vitamin B-1 (thiamine HCl) 100 mg oral Daily
7. Rifaximin 550 mg PO BID
8. Sorafenib 400 mg PO BID
9. Lactulose 60 mL PO TID
10. Citalopram 20 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Furosemide 40 mg PO DAILY
13. Gabapentin 900 mg PO TID
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL 30 mL by mouth three times a day
Disp #*5 Bottle Refills:*3
4. LeVETiracetam 750 mg PO BID
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Rifaximin 550 mg PO BID
9. Furosemide 80 mg PO QD-TID:PRN shortness of breath w/signs of
fluid overload
RX *furosemide 80 mg 1 tablet(s) by mouth QD-TID:PRN Disp #*90
Tablet Refills:*0
10. Ondansetron ___ mg PO Q6-8H:PRN nausea
RX *ondansetron 4 mg ___ tablet,disintegrating(s) by mouth
Q6-8H:PRN Disp #*90 Tablet Refills:*0
11. Ursodiol 250 mg PO TID
RX *ursodiol 250 mg 1 tablet(s) by mouth three times a day Disp
#*90 Capsule Refills:*1
12. Vitamin B-1 (thiamine HCl) 100 mg oral Daily
13. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO
Q1-4H:PRN pain / shortness of breath
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.05-0.25 mL by
mouth every 1 to 4h Disp #*1 Bottle Refills:*3
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Hepatic Encephalopathy, Acute Kidney Injury,
Secondary: Cirrhosis, Multifocal Hepatocellular Carcinoma,
Portal venous system thromboses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You came with diarrhea and worsening
jaundice. We held your chemotherapy and the diarrhea improved.
We did an MRI of your liver and found that your cancer was very
advanced and was obstructing your liver vessels and bile ducts.
You were seen by medical and radiation oncologists who believed
that any treatment to your cancer would likely worsen your
condition and not improve it. Your condition is very serious and
your comfort during the next few remaining weeks should be the
main goal of your treatment. When we let you know that doing
chest compressions on you would cause you harm and would likely
not prolong your life much you told us that you would not like
to be harmed by CPR. You also let us know that you would feel
better at ___ and we are following your wishes.
We wish the best forward,
Your ___ Team
Followup Instructions:
___
|
10411115-DS-14 | 10,411,115 | 25,901,322 | DS | 14 | 2160-10-29 00:00:00 | 2161-01-08 18:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chief Complaint: fever, cough, sob
Reason for MICU transfer: hyponatremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of severe as, suspected CAD, DM, HTN, HLD,
presenting with cough x 5 days, started suddenly, worsening.
Non-productive except for one time of grey sputum. No sick
contacts. Associated with new SOB today. Subjective fevers, only
checked temp once this AM at 37.7. Denies cp/n/v/exertional
dyspnea/pnd/orthopnea. Has noticed some weight gain over the
past week, no major changes to diet, no changes in the
medications in the past few months.
In the ED, initial vitals:
12:06 0 97.0 108 160/86 20 98%
14:06 0 77 146/53 18 95% RA
15:01 98.6 72 134/56 16 96% RA
15:01 0 98.6 72 134/56 16 96% Nasal Cannula
Labs notable for: hypona to 117, previously 136 months. WBC 11.1
with left shift. Lactate 3.6.
Imaging: CXR concerning for PNA per ED read.
Recommendations: Given ctx, azithro, aspirin. Admit to ICU for
further management of hyponatremia.
On arrival to the FICU, patient again denies cp/n/v. Continues
to have non-productive cough and some shortness of breath.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
PAST MEDICAL HISTORY:
- Aortic stenosis with plan for repeat ECHO in ___ year, good
functional capacity at last cardiology visit
- Hypertension
- Hypercholesterolemia
- Type II diabetes mellitus
- Chest pain - The patient has probable coronary artery disease
manifested as stable exertional angina.
- Gastroesophageal reflux disease
- Osteoporosis
- Sciatica
- Lumbar spinal stenosis
PAST SURGICAL HISTORY:
1. Bilateral cataract removal
2. Cholecystectomy
3. I&D vaginal abscess - ___
Social History:
___
Family History:
mother had a stroke at age ___. Her father
had a stroke at age ___. Her brother had both breast and lung
cancer. He died from the latter and her other brother had a
heart attack.
Physical Exam:
Admission:
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
NECK: supple, JVP at or slightly above clavicle sitting up in
bed, and also with respirofilling variation of EJ
LUNGS: Decreased bs with crackles lll, otherwise good air
movement
CV: Crescendo-decrescendo murmur best heard over apex, some
radiation to caroitds
ABD: obese, distended, soft, +BS, no g/r/r
EXT: Warm, well perfused, 2+ pulses, 1+ pitting edema around
ankls with compression stockings in place
SKIN: wwp
NEURO: AAOx3 per above, movign all extremities
Discharge:
Pertinent Results:
Admission Labs:
___ 01:02PM BLOOD WBC-11.1* RBC-3.76* Hgb-10.9* Hct-30.8*
MCV-82 MCH-29.0 MCHC-35.4 RDW-12.2 RDWSD-36.2 Plt ___
___ 01:02PM BLOOD Neuts-76.8* Lymphs-10.5* Monos-11.6
Eos-0.3* Baso-0.2 Im ___ AbsNeut-8.52* AbsLymp-1.16*
AbsMono-1.28* AbsEos-0.03* AbsBaso-0.02
___ 01:02PM BLOOD ___ PTT-28.5 ___
___ 01:02PM BLOOD Glucose-239* UreaN-9 Creat-0.5 Na-117*
K-3.2* Cl-79* HCO3-23 AnGap-18
___ 01:02PM BLOOD Calcium-9.2 Phos-2.2*# Mg-1.5*
___ 01:02PM BLOOD cTropnT-<0.01
___ 01:02PM BLOOD proBNP-712*
___ 01:16PM BLOOD Lactate-3.6*
___ 05:17PM BLOOD Lactate-2.8*
___ 01:02PM BLOOD Osmolal-245*
___ 02:00PM URINE Color-Straw Appear-Clear Sp ___
___ 02:00PM URINE Blood-SM Nitrite-POS Protein-TR
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 02:00PM URINE RBC-1 WBC-16* Bacteri-MANY Yeast-NONE
Epi-0
___ 02:00PM URINE Hours-RANDOM Creat-31 Na-97 K-40 Cl-127
___ 02:00PM URINE Osmolal-466
Pertinent Labs:
Discharge Labs:
Imaging/Reports:
- CXR ___:
FINDINGS:
Heart size is top normal. Mediastinal and hilar contours are
unchanged.
Pulmonary vasculature is normal. Lungs are hyperinflated.
Minimal
atelectasis is noted in the left base. No focal consolidation,
pleural effusion or pneumothorax is present. Calcified
granuloma within the periphery of the right upper lobe is
unchanged. Moderate multilevel degenerative changes are again
seen in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Micro:
- blood, urine cx pending
Brief Hospital Course:
___ with AS, suspected CAD, DM, HTN, HLD presenting with
hyponatremia, pna.
# Hyponatremia: New for patient, likely SIADH based on urine Na
and osms. Patient was originally admitted to ICU for Na 113 and
improved with fluid restriction and salt tabs. Continued fluid
restriction on d/c and stopped diurectic.
# Sepsis secondary to pneumonia vs UTI: Patient presented with
cough, tachycardia, leukocytosis, and lactic acidosis. CXR was
suspicious for pneumonia. Urine culture was positive for E coli.
The patient was put on CTX/azithro. She completed 5 days of
azithro and was discharged with cefpodoxime to complete a 10 day
course.
HTN: continued home coreg, amlodipine. Stopped diuretic due to
hyponatremia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Valsartan 160 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. MetFORMIN (Glucophage) 1000 mg PO DAILY
5. MetFORMIN (Glucophage) 1500 mg PO QHS
6. Alendronate Sodium 70 mg PO 1X/WEEK (___)
7. Docusate Sodium 100 mg PO BID
8. Senna 25.8 mg PO DAILY
9. Amlodipine 5 mg PO DAILY
10. Carbamide Peroxide 6.5% 5 DROP AD QHS
11. Simvastatin 10 mg PO QPM
12. Nitroglycerin SL 0.3 mg SL Frequency is Unknown
13. Omeprazole 40 mg PO PRN indigestion
14. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg calcium (1,500 mg)-400 unit oral BID
15. GlipiZIDE 10 mg PO DAILY
16. GlipiZIDE 7.5 mg PO QPM
17. Hydrochlorothiazide 25 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Simvastatin 10 mg PO QPM
5. Valsartan 160 mg PO DAILY
6. Acetaminophen 1000 mg PO Q8H:PRN pain
7. Alendronate Sodium 70 mg PO 1X/WEEK (___)
8. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg calcium (1,500 mg)-400 unit oral BID
9. Carbamide Peroxide 6.5% 5 DROP AD QHS
10. GlipiZIDE 10 mg PO DAILY
11. GlipiZIDE 7.5 mg PO QPM
12. MetFORMIN (Glucophage) 1000 mg PO DAILY
13. MetFORMIN (Glucophage) 1500 mg PO QHS
14. Nitroglycerin SL 0.3 mg SL PRN chest pain
15. Omeprazole 40 mg PO PRN indigestion
16. Senna 25.8 mg PO DAILY
17. Vitamin D 1000 UNIT PO DAILY
18. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth every
six (6) hours Refills:*0
19. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Hyponatremia
SIADH
Pneumonia
Hyponatremia
SIADH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mrs. ___, you were admitted due pneumonia and low sodium
levels. Your pneumonia improved on antiobiotics. Please finish
all antibiotics even if you are feeling well. Your sodium levels
are improving but remain low. Please continue to limit your
water intake as you have been in the hospital.
Followup Instructions:
___
|
10411160-DS-7 | 10,411,160 | 29,279,148 | DS | 7 | 2162-10-11 00:00:00 | 2162-10-11 19:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Abilify / codeine / Maalox Maximum Strength / ACE Inhibitors
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___ - HD Catheter insertion
___ - Endoscopic Ultrasound
History of Present Illness:
___ h/o CKDV (not yet on HD, has AVF but not ready for use),
OSA, schizoaffective disorder, HFpEF who presented to ___
___ with altered mental status. There was initial concern
for TIA with left facial droop and dysarthria, but ultimately
this was felt to be his baseline secondary to Bell's palsy.
He has been noted to be more confused with waxing and waning
mental status, concerning for uremia versus delirium. Creatinine
was 9 on admission with BUN in the ___. Diuretics were initially
held due to high creatinine but patient became hypoxic and Lasix
was initiated. Transfer is being requested to initiate dialysis.
Workup so far has been: negative head CT, negative UA, no
hydronephrosis on renal u/s, CXR with mild emphysema but not
acute pulmonary process, most recent BUN/Cr 81/8.7.
Regarding his AV fistula, this was placed on ___ in the right
forearm by Dr. ___. There was no palpable thrill over the
graft site, but on two prior occasions Dr. ___ detected a
signal using Doppler. Overall flow was too low to use and plan
was to allow several more weeks for graft to heal before
fistulogram.
Patient presenting for workup of altered mental status and
likely HD initiation. On floor today he states that he "feels
like he is in and out of a trance." He notes being quite sleepy.
Denies fevers, chills, nausea, vomiting.
Past Medical History:
- CKD Stage V
- Schizoaffective disorder
- Anemia
- Bell's Palsy
- HFpEF
- COPD with Asthma
- DMII
- Gout
- HTN
- Pancreatitis
Social History:
___
Family History:
Father: T2DM, died from MVA
Mother: ___, afib, deceased
No family history of kidney disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: 97.2 153 / 90 54 18 92 RA
GENERAL: NAD
HEENT: Clear oropharynx, MMMs
NECK: nontender supple neck. Difficult to appreciate JVP ___
habits
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB on anterior auscultation. Breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema. Positive asterixis
NEURO: CN II-XII intact. Mild left facial droop and dysarthria.
A&Ox3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
======================
VS: 97.9 PO 148 / 98 77 18 93 Ra
GENERAL: NAD, alert and oriented x 3
HEENT: Clear oropharynx, MMMs
NECK: nontender supple neck
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB. No wheezes or rhonchi. Left chest HD line is has
some dried blood, but is nonerythematous, nontender, and dry.
ABDOMEN: Nondistended, +BS, nontender in all quadrants, no
rebound/guarding.
EXTREMITIES: No cyanosis, clubbing or edema.
NEURO: CN II-XII grossly intact.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. No pitting edema in bilateral lower extremity.
Pertinent Results:
ADMISSION LAB RESULTS
====================
___ 02:37PM BLOOD WBC-5.1 RBC-2.57* Hgb-8.5* Hct-25.3*
MCV-98 MCH-33.1* MCHC-33.6 RDW-14.6 RDWSD-52.4* Plt Ct-84*
___ 02:37PM BLOOD ___ PTT-41.3* ___
___ 02:37PM BLOOD Glucose-71 UreaN-76* Creat-8.2*# Na-138
K-4.4 Cl-104 HCO3-22 AnGap-16
___ 02:37PM BLOOD ALT-12 AST-11 LD(LDH)-175 AlkPhos-47
TotBili-0.2
___ 02:37PM BLOOD Albumin-2.4* Calcium-7.8* Phos-3.2 Mg-2.4
Iron-190*
___ 02:37PM BLOOD calTIBC-195* VitB12-985* Hapto-39
Ferritn-556* TRF-150*
DISCHARGE LAB RESULTS
====================
___ 07:00AM BLOOD WBC-10.9* RBC-2.46* Hgb-7.9* Hct-23.9*
MCV-97 MCH-32.1* MCHC-33.1 RDW-15.6* RDWSD-53.1* Plt ___
___ 07:10AM BLOOD Glucose-71 UreaN-19 Creat-3.5* Na-129*
K-4.0 Cl-95* HCO3-23 AnGap-15
___ 07:10AM BLOOD Calcium-6.4* Phos-3.0 Mg-1.8
IMAGING/STUDIES
==============
EUS ___:
Impression:
EUS: Pancreas parenchyma: The uncinate process / head / body /
tail of the pancreas showed the following parenchymal changes :
lobularity and hyperechoic strands.
- Pancreas duct: The pancreas duct was dilated and measured
10mm in maximum diameter in the head of the pancreas with large
hyperechoic focus with anechoic shadow consistent with PD stone.
The duct was normal between the stone and the ampulla. The PD in
the body was dilated with multiple hyperechoic foci with
anechoic shadows consistent with stones. There was minimal
parechymal tissue surrounding the duct in the body.
- There was no evidence of IPMN.
- Bile duct: The bile duct was imaged at the level of the
porta-hepatis, head of the pancreas and ampulla. The maximum
diameter of the bile duct was 5 mm. The bile duct was normal in
appearance. No intrinsic stones or sludge were noted. The bile
duct and the pancreatic duct were imaged within the ampulla and
appeared normal.
- The ampulla was visualized endoscopically with both the
echoendoscope as well as a duodenoscope. It appeared normal.
There were no ampullary lesions and/or fishmouth appearances
noted.
Renal US ___:
IMPRESSION:
1. No definite evidence of a solid renal mass though evaluation
is markedly limited. If there is further concern recommend MRI
kidneys with contrast.
2. Hyperechoic renal cortex, compatible with medical renal
disease.
MRCP ___
IMPRESSION:
1. Atrophic pancreas with main pancreatic duct dilatation. The
differential considerations would include chronic pancreatitis
with a duct stricture, however, main duct IPMN cannot be
excluded. ERCP is suggested.
2. T2 hypointense lesion within the interpolar region of the
left kidney. This could represent a hemorrhagic cyst, however,
given that contrast was not administered, a solid renal mass
cannot be excluded.
3. Bilateral pleural effusions.
Brief Hospital Course:
Mr. ___ is ___ h/o CKD stage 5, developmental delay, OSA,
schizoaffective disorder, HFpEF who presented to ___
___ with altered mental status transferred to ___ for HD
initiation. His hospital course was complicated by development
of pneumonia with concern for septic shock requiring MICU
transfer. The patient was started on broad spectrum antibiotics,
and started on pressors. As he improved, he was transferred back
to the floor on broad spectrum antibiotics. He completed a 7 day
course of treatment for healthcare associated pneumonia.
#ESRD on dialysis
#Right forearm graft
A temporary HD catheter was inserted on ___, and the patient was
started on HD on ___. PPD was negative this admission, On ___, a
tunneled HD line was placed and HD was initiated on ___. His HD
schedule is ___. His right forearm AV
graft placed on ___ by Dr. ___ at ___. This graft was
occulded on venogram. Graft revision surgery was delayed by the
development of healthcare associated pneumonia and septic shock.
He was discharged with the plan to complete new right arm
proximal graft as an outpatient.
Outpatient Dialysis is scheduled for every ___, ___ & ___ at
11:00am. It will be completed at:
___
Phone: ___
#Dilated Pancreatic Duct
#Pancreatic Duct Stone
An abdominal ultrasound and MRCP showed an atrophic pancreas
with main pancreatic duct dilatation. EUS showed findings
consistent with several pancreatic duct stones. Since the
patient was asymptomatic, no intervention was taken.
#Renal Lesion
A renal lesion was found incidentally on left kidney. Renal US
is uninformative. Per radiology the lesion is believed to be
hemorrhagic. Given the patient's kidney function MRI with
gadolinium is not possible given risk for nephrogenic sclerosis
fibrosis. Triphasic CT can be considered in conjunction with
follow-on HD. Alternatively, a repeat renal ultrasound can be
completed as an outpatient.
# Hypoxic respiratory failure
# Septic Shock
# HCAP
# COPD
The patient was in septic shock and the source was likely a
healthcare associated pneumonia seen on CT. CTA was negative for
PE. The patient completed Vanc/Ceftazidime/Azithro x 7 days. He
was also given stress dose steroids in case the hypoxic
respiratory failure was caused by a COPD exacerbation. His
steroids were tapered from Prednisone 40mg daily to 20 mg PO x 2
days. The last day of steroids was ___. He was continued on
fluticasone/salmeterol 250/50 BID, Tiotropium 1CAP IH daily.
#Primary Hypoparathyroidism
PTH low (6) on ___ iCa low 0.94 (___). Vitamin D 32 (___).
Per endocrine and OSH records, this is known hypoparathyroidism.
He received IV calcium gluconate on ___. He was started on
calcium carbonate 500mg TID. Consider activated vitamin D
supplementation as an outpatient.
# Normocytic Anemia
B12 985 (>nl), no recent folate. TIBC low (195), Ferritin high
(556), Iron slightly high (190). Likely anemia of chronic
disease I/s/o ESRD.
#Thrombocytopenia
Platelet nadir 66. Patient's baseline plts is 140-200; past
fibrinogen wnl. Unlikely HIT (4T 3). PF4 antibody negative.
Platelets gradually improved throughout the hospitalization.
#Schizoaffective disorder
He was continued on Olanzpaine 12.5mg and Depakote 750 mg q12.
# Gout:
He was continued on allopurinol ___ dosed every other day.
#CAD:
Continued ASA81
#BPH:
Held Terazosin 2mg due to hypotension
TRANSITIONAL ISSUES:
====================
#ESRD
- Transplant surgery will not do graft access this admission
because of the recent infection. ___ will contact his
house and schedule him for outpatient access. He does not need
to go to transplant clinic. Her phone number is ___
- Dialysis ___
- Patient should get an ultrasound on kidney before ___
to further evaluated hemorrhagic renal cyst.
- Consider activated Vitamin D or high-dose calcium
supplementation for hypoparathyroidism as he was consistently
hypocalcemic throughout the hospitalization. Would monitor Ca
every ___ days to ensure stability.
- Tamsulosin and Metoprolol held in setting of low blood
pressures. Restart as tolerated.
- Of note, WBC mildly elevated at the time of discharge. Would
consider repeating in 1 week to ensure stability.
# Communication/HCP: ___ ___
# Code: DNR, ok to intubate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Senna 8.6 mg PO QHS:PRN constipation
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. sevelamer CARBONATE 1600 mg PO TID W/MEALS
4. Furosemide 60 mg PO DAILY
5. OLANZapine 12.5 mg PO QHS
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Allopurinol ___ mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Divalproex (DELayed Release) 750 mg PO BID
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Terazosin 2 mg PO QHS
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Sodium Bicarbonate 650 mg PO TID
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID
2. Calcium Carbonate 500 mg PO TID
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
4. Nephrocaps 1 CAP PO DAILY
5. Allopurinol ___ mg PO EVERY OTHER DAY
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Divalproex (DELayed Release) 750 mg PO BID
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. OLANZapine 12.5 mg PO QHS
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 8.6 mg PO QHS:PRN constipation
15. Tiotropium Bromide 1 CAP IH DAILY
16. HELD- Terazosin 2 mg PO QHS This medication was held. Do
not restart Terazosin until you are told to do so by your
primary care doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- End stage renal disease on hemodialysis
- Healthcare associated pneumonia
- Main pancreatic duct stone
Secondary:
- Primary hypoparathyroidism causing hypocalcemia
- Anemia
- Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___
Why did you come to the hospital?
=========================
- You came to the hospital because change in your kidney
function, confusion, and the need to start hemodialysis.
What did we do for you?
==================
- We started you on hemodialysis
- We gave you antibiotics to treat a pneumonia
- You had an ultrasound to look at a dilated pancreatic duct
- You had an ultrasound to look at a renal cyst
- We gave you calcium for your low calcium level
What do you need to do?
==================
- Plan to attend hemodialysis three times per week
- Follow-up with the transplant surgery team to have a revision
to your right arm venous graft.
- Notify your primary care doctor if you start to develop
persistent belly pain and changes in your stooling.
- You will need to get an ultrasound of your kidney as an
outpatient
It was a pleasure taking care of you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10411160-DS-8 | 10,411,160 | 20,168,442 | DS | 8 | 2162-12-14 00:00:00 | 2162-12-14 19:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Abilify / codeine / Maalox Maximum Strength / ACE Inhibitors
Attending: ___.
Chief Complaint:
RUE swelling, pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with ESRD on HD (___), OSA,
schizoaffective disorder, HFpEF who presents with RUE pain and
swelling.
He presents with right upper extremity pain and swelling that
has been worsening over the past few days. Location of these are
at the AV fistula he had placed. He has noticed spreading
redness for the past ___ days, it is minimally painful. Denies
any numbness or weakness of his distal extremity. Denies fever
or chills. Denies chest pain or shortness of breath. He also has
a dialysis catheter on the left and was able to receive dialysis
through this yesterday.
Of note his right upper extremity AV graft was placed by Dr.
___ on ___. He then underwent a fistulogram on ___, which
revealed stenosis of the venous component. The stent was
replaced at that point, and he also underwent aspiration of a
seroma in that region.
In the ED, initial vitals were:
97.9 75 131/77 18 100% RA
- Exam notable for:
Large area of minimally tender fluctuance to the inner right
arm, there is a brisk thrill over the region of the distal
graft. Faint but intact radial pulse. Intact sensation and motor
function.
- Labs notable for:
Lactate 2.5
K 3.0
INR 1.4
WBC 7.3, Hgb 10.1, Plt 137
- He was seen by ___ and transplant surgery. Findings were felt
to be consistent with reaccumulation of known perigraft seroma,
no infection on exam. Transplant surgery recommended admission
to medicine for consideration of repeat fistulagram due to
concern for re-stenosis of AV graft
- Vitals prior to transfer:
97.9 79 103/70 18 96% RA
Upon arrival to the floor, patient reports persistent pain in
the right arm. Otherwise no new complaints.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
PAST MEDICAL HISTORY:
ESRD
Schizoaffective disorder
Anemia
Bell's Palsy
HFpEF
COPD with Asthma
DMII
Gout
HTN
Pancreatitis
___ Right loop forearm AV graft
Social History:
___
Family History:
Father: T2DM, died from MVA
Mother: ___, afib, deceased
No family history of kidney disease
Physical Exam:
Admission PHYSICAL EXAM:
Vital Signs: 97.6 117/80 80 18 93 RA
General: Alert, oriented, no acute distress. Appears
frustrated.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Crackles at bases bilaterally with faint expiratory
wheeze.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused. 2+ bilateral ___ pitting edema.
RUE with large upper extremity fluid collection, and associated
wide area of ecchymosis. Thrill is intact over AV graft and
radial pulse is palpable.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge PHYSICAL EXAM:
VS: 97.4 PO 104 / 71 78 18 93 Ra
General: Alert, oriented, no acute distress. flat affect.
HEENT: Sclerae anicteric, nc/at, no conjunctival pallor
Neck: Supple. JVP estimated 10 cm above RA
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused. 2+ bilateral ___ pitting edema. legs
feel very full
RUE with large upper extremity fluid collection in medial upper
arm, associated wide area of ecchymosis extending to posterior
and lateral upper arm almost to elbow. minimal tenderness,
non-induarted, no increased warmth at area. Thrill is intact
over AV graft, +bruit, radial pulse is palpable. L subclavian
temporary HD catheter c/d/I.
Neuro: grossly intact, moving all extremities
Pertinent Results:
Labs:
=====
___ 06:45PM BLOOD WBC-7.3 RBC-3.18*# Hgb-10.1*# Hct-31.4*#
MCV-99* MCH-31.8 MCHC-32.2 RDW-16.7* RDWSD-59.9* Plt ___
___ 06:45PM BLOOD Neuts-46.9 ___ Monos-11.7 Eos-1.7
Baso-0.4 NRBC-0.3* Im ___ AbsNeut-3.41 AbsLymp-2.83
AbsMono-0.85* AbsEos-0.12 AbsBaso-0.03
___ 04:31AM BLOOD ___ PTT-37.6* ___
___ 06:45PM BLOOD Glucose-74 UreaN-8 Creat-2.9* Na-126*
K-6.8* Cl-92* HCO3-27 AnGap-14
___ 04:31AM BLOOD Glucose-75 UreaN-9 Creat-3.2* Na-135
K-3.0* Cl-98 HCO3-29 AnGap-11
___ 04:31AM BLOOD Calcium-6.1* Phos-2.6* Mg-1.6
___ 06:53PM BLOOD Lactate-2.5* K-5.9*
___ 10:34PM BLOOD K-3.0*
___ 04:28AM BLOOD WBC-6.6 RBC-2.92* Hgb-9.4* Hct-29.4*
MCV-101* MCH-32.2* MCHC-32.0 RDW-16.2* RDWSD-59.7* Plt ___
___ 04:28AM BLOOD Glucose-94 UreaN-13 Creat-3.7* Na-132*
K-3.3 Cl-98 HCO3-27 AnGap-10
___ 04:28AM BLOOD Calcium-6.1* Phos-3.2 Mg-1.7
Studies:
========
-RUE US ___:
IMPRESSION:
Patent right upper extremity AV graft.
Nonvascular mass adjacent to the AV graft likely represents
known recurrent
seroma.
No evidence of pseudoaneurysm.
Brief Hospital Course:
Mr. ___ is a ___ with ESRD on HD (___), DM2, HFpEF and
schizoaffective disorder, who presented with RUE pain and
swelling, and concern for reaccumulation of fluid collection at
AV fistula site. Of note, his AVF was placed ___ and he
required stenting for stenosis of the venous portion of his
graft on ___. At that time a seroma was also drained. He was
seen by Transplant Surgery and ___. He underwent RUE US with
Doppler that showed patent AV graft and fluid collection thought
to be seroma. Fistulogram was deferred given ultrasound results.
The graft was accessed for hemodialysis on ___, during which 3L
were removed. He was discharged home with plans to continue HD
on T/S/S.
TRANSITIONAL ISSUES
===================
-Graft OK to use for HD. also has temporary L sided HD catheter.
Please remove temporary HD line as soon as feasible to avoid
infection.
-Consider drainage of seroma and/or fistulogram if patient
develops worsening symptoms, signs of neurovascular compromise,
or loss of function in AV graft
-Patient was significantly hypervolemic on exam and symptomatic
from fluid overload in lower extremities. Please remove volume
as tolerated at next HD session. Discharge weight 107.4 kg after
3L were removed at HD on ___. Discharge weight 108.8 kg
___.
-Contact information for outpatient dialysis: ___
___ Dialysis ___ / ___
___ / Phone: ___
# CODE: DNR, ok to intubate (MOLST on file)
# CONTACT: ___
Relationship: sibling
Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q4H
2. Calcium Carbonate 500 mg PO TID
3. Divalproex (DELayed Release) 750 mg PO BID
4. Allopurinol ___ mg PO EVERY OTHER DAY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. OLANZapine (Disintegrating Tablet) 12.5 mg PO QHS
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO QHS
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Aspirin 81 mg PO DAILY
12. Fish Oil (Omega 3) 1000 mg PO DAILY
13. Hydrocortisone Cream 2.5% 1 Appl TP BID
14. GuaiFENesin ___ mL PO TID:PRN cough
15. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q4H
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO TID
5. Divalproex (DELayed Release) 750 mg PO BID
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. GuaiFENesin ___ mL PO TID:PRN cough
9. Hydrocortisone Cream 2.5% 1 Appl TP BID
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Nephrocaps 1 CAP PO DAILY
12. OLANZapine (Disintegrating Tablet) 12.5 mg PO QHS
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 8.6 mg PO QHS
15. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: End Stage Renal Disease
Secondary: Schizoaffective disorder, Heart Failure with
Preserved Ejection Fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were seen at ___ for right arm pain and swelling.
WHILE YOU WERE IN THE HOSPITAL
-We did not think you had an infection of your arm.
-We looked at your right arm with an ultrasound, which showed an
open, working graft and stable fluid collection.
-The graft in your right arm was functioning for dialysis on
___.
WHAT YOU SHOULD DO NOW
-Continue dialysis three days a week.
-We plan to have the extra fluid in your body removed with
dialysis. This should help your legs feel better.
-Call your doctor if you develop worsening pain, weakness or
loss of sensation in your right arm.
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
10411387-DS-10 | 10,411,387 | 20,720,895 | DS | 10 | 2151-06-20 00:00:00 | 2151-06-20 20:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / Dilaudid
Attending: ___.
Chief Complaint:
pneumonia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o CAD with 5v CABG, CVA, bilateral carotid disease s/p
CEA, COPD, presenting from nursing facility with weakness.
History from patient is limited. Per transfer records, patient
has been fatigued over past several days. Labs were checked and
leukocytosis (WBC 13) was noted; additionally, his stools were
reportedly guaiac (+). He was recently on amox-clavulanate
course for "chest congestion."
In the ED, initial VS were 98.5 86 119/64 16 94% 2L.
Labs showed Neg flu swab, WBC 16.3 88.9%N, Cr 1.3, trop 0.06,
lactate 2.1. CXR was concerning for PNA.
Received 500cc NS, 750mg levofloxacin IV, ASA 325mg
Transfer VS were 100.6 80 102/58 18 97% RA.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient appears disoriented and asks if
his name is ___. He is unable to reliably recount any history,
and has difficulty with ROS. He describes ongoing productive
cough but denies chest discomfort, shortness of breath, or pain
anywhere. He is unable to answer more specific questions about
fevers, chills, abdominal pain, stool habits, skin lesions,
neurologic symptoms.
Past Medical History:
PMH
- Past ischemic stroke (early, at age ___,
Bilateral carotid stenosis (L ICA 100% occlusion, R ICA 60-69%),
Right vertebral artery stenosis (CTA ___ CVA and carotid
endarterectomy in ___.
- CAD s/p CABGx5 (___)
- HTN
- HLD
- COPD
- Prostate Cancer s/p Prostatectomy
- systolic heart failure (EF 40% in ___
PSH
- s/p Prostatectomy (for PrCa)
- s/p Appendectomy
-carotid endarterectomy ___
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION
VS - 98.1 105/51 71 18 98/2L
GENERAL: NAD, lying comfortably in bed
HEENT: EOMI, PERRL, anicteric sclerae, MMM, poor dentition
CARDIAC: Distant heart sounds. Normocardic, regular, ___ SEM
loudest at ___.
VASCULAR: No JVD, no ___ edema
PULM: RR>20. No incr WOB or use of accessory mm. Distant
respiratory sounds. Bibasilar crackles. Rhonchi most prominent
in upper lobes. No wheezes.
ABDOMEN: Soft, ntnd, no palp HSM or organomegaly.
MSK: wwp. charcot deformity of bilateral feet
NEURO: AOx1 (name only), CN II-XII intact,
SKIN: no rashes or lesions on anterior ___
___
Tele - HR ___, no alarms
GENERAL: NAD, lying comfortably in bed
HEENT: EOMI, PERRL, anicteric sclerae, MMM, poor dentition
CARDIAC: Distant heart sounds. Normocardic, regular, ___ SEM
loudest at ___.
VASCULAR: No JVD, no ___ edema
PULM: RR>20. No incr WOB or use of accessory mm. Distant
respiratory sounds. Bibasilar crackles. Rhonchi most prominent
in upper lobes. No wheezes.
ABDOMEN: Soft, ntnd, no palp HSM or organomegaly.
MSK: wwp. charcot deformity of bilateral feet
NEURO: AOx1 (name only), CN II-XII intact,
SKIN: no rashes or lesions on anterior ___
___ Results:
====================================
LABS
====================================
Admission
___ 04:15PM BLOOD WBC-16.3*# RBC-3.14* Hgb-9.5* Hct-28.5*
MCV-91 MCH-30.1 MCHC-33.1 RDW-13.6 Plt ___
___ 04:15PM BLOOD Neuts-88.9* Lymphs-6.3* Monos-4.5 Eos-0.2
Baso-0.2
___ 04:15PM BLOOD ___ PTT-27.6 ___
___ 04:15PM BLOOD Glucose-280* UreaN-35* Creat-1.3* Na-134
K-3.5 Cl-97 HCO3-21* AnGap-20
___ 04:15PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
___ 04:15PM BLOOD Lactate-2.1*
Cardiac biomarkers
___ 04:15PM BLOOD cTropnT-0.06*
___ 12:13AM BLOOD CK-MB-2 cTropnT-0.05*
___ 07:40AM BLOOD CK-MB-2 cTropnT-0.04*
Discharge
___ 07:35AM BLOOD WBC-11.8* RBC-3.12* Hgb-9.4* Hct-28.2*
MCV-90 MCH-30.0 MCHC-33.2 RDW-13.5 Plt ___
___ 07:35AM BLOOD Glucose-155* UreaN-23* Creat-0.9 Na-132*
K-4.4 Cl-100 HCO3-19* AnGap-17
___ 07:35AM BLOOD ALT-17 AST-24 AlkPhos-74 TotBili-0.5
___ 07:35AM BLOOD Calcium-8.6 Phos-1.9* Mg-1.6
___ 07:40AM BLOOD %HbA1c-7.7* eAG-174*
====================================
STUDIES
====================================
___ Imaging CHEST (PA & LAT)
FINDINGS:
PA and lateral views of the chest provided. Midline sternotomy
wires
mediastinal clips again noted. Mild cardiomegaly unchanged with
a retrocardiac opacity concerning for pneumonia in the left
lower lobe. The right lung appears largely clear. No large
effusion or pneumothorax is seen. Mediastinal and hilar
configuration is unchanged and normal. Bony structures are
intact.
IMPRESSION:
Left lower lobe opacity concerning for pneumonia. Stable mild
cardiomegaly.
Brief Hospital Course:
___ h/o CAD with 5v CABG, CVA, bilateral carotid disease s/p
CEA, COPD, presenting from nursing facility with weakness and
guaiac positive stools, found to have multiple lab
abnormalities. Most likely he developed healthcare associated
pneumonia and preseptic physiology, which resulted in relative
hypotension and subsequent ___, lactatemia. He was
initiated on broad-spectrum antibiotics (vanc/cefepime)
overnight, with improvement in BPs. Given clinical stability and
low suspicion for an MDR-driven pneumonia, ABX were de-escalated
to levofloxacin. Re: ___, no ischemic findings on ECG
and peaked at 0.06, flat x3 measurements. Re: ___, Cr elevated
to 1.3 on elevation and returned to normal with 1L crystalloid
and antibiotics as above. Discharged back to his rehab facility
with improvement in all clinical problems.
ACTIVE PROBLEM LIST
Leukocytosis
HCAP
Hypotension
___
Hyperglycemia
Anemia
# Leukocytosis: with PMN predominance. Unclear etiology and pt
himself unable to provide details. Most likely given available
information is pulmonary source (cough, CXR with opacities).
Other potential sources of infection should be entertained. Most
likely in this pt are skin and urine. No obvious skin
impairment; clean catch urine with no e/o UTI. On admission,
data concerning for early sepsis. That is, he is on three
different blood pressure agents (see below) and his SBP is 100s;
there is no documentation of receiving home medications in our
ED, which suggests relative hypotension. He also had lab
evidence of relative hypotension ___, lactatemia,
___.
An infectious workup was sent (BCX/UCX). HCAP was treated as
below. Telemetry was initiated on the first night for close
monitoring and discontinued when no abnormalities were noted.
# HCAP: Patient with cough, CXR opacity, O2 requirement (unclear
if new). Also unclear if any fevers at OSH, none at ___. Given
that he resides at ___, he should be tx'ed for HCAP.
Complicating this picture is a reported hx of COPD, though no
PFTs are available and he is not apparently on any medications
for COPD; there is no wheezing on exam or increased WOB to
suggest an exacerbation.
He was initially treated with vanc/cefepime and, given low
suspicion for MRSA/pseudomonas pneumonia, was de-escalated to
levofloxacin once stable on RA.
He was discharged to ___ with levoflox 750 q24 x 10d course to
end ___.
# Hypotension: On admit, patient with multiple features
suggesting hypoperfusion including ___, elevated
lactate, and SBP 100s in the absence of 3x BP meds as above.
Most likely causes include hypovolemic vs early septic
physiology. Mgmt of HCAP as above. 500cc crystalloid bolus.
After receiving vanc/cefepime on the first hospital night, his
SBPs improved to 130s-150s. Home blood pressure medications were
held and should be resumed as outpatient as needed for
hypertension.
# ___: Most likely represents Type II ischemia in the
setting of relative hypotension. Got ASA 325 in ED. Cont
atorvastatin. Low suspicion for ACS given absence of sxs or
concerning ECG changes. Trended cardiac biomarkers (Tn 0.06,
0.05, 0.04).
# ___: Most likely ___ hypoperfusion. Tx infxn and hypovolemia
as above. Renally dose meds, avoid nephrotoxins. Cr returned to
normal with these measures.
# Hyperglycemia: Initially suspect DM in this pt with fasting
glucose 280s and ?Charcot deformity of bilateral feet. A1c was
sent and was 7.7%. In house, fingersticks were 100s-200s; he was
kept on humalog ISS.
# Anemia: Unclear etiology. No obvious bleeding or hemolysis;
most likely represents AOCD. Initially, T+C 2u overnight and
ensured adequate access as above. Per PCP, ___ baseline Hct
~34. Most likely this represents occult GIB given brown stools
guaiac (+). Should have appropriate workup as outpatient.
# Electrolyte abnormalities: Hypophosphatemia and mild
hyponatremia were noted on day of discharge. Will need repeat
CHEM 10 as outpatient to ensure resolution.
CHRONIC
# HTN: held losartan, HCTZ for SBP 100s
# CAD: cont atorva, metoprolol at decreased dose
# Hypothyroidism: cont levothyroxine
# GERD: cont omeprazole
# Psychiatric: cont citalopram
# Constipation: cont docusate, bisacodyl
# Indigestion: cont home milk of mag
TRANSITIONAL
-Deconditioning: Will need full ___ eval upon return to extended
care facility
-PNA: needs close f/u to ensure treatment to resolution
-Anemia: ___ H/H off their historical baseline in setting of
brown guaiac (+) stools. may have occult GIB. should receive
appropriate workup that is within the limits of ___ goals of
care.
- holding losartan, HCTZ at discharge; SBPs 130s to 150s. Per
JNC8, goal BP for this gentleman is <150/90.
- decr metoprolol succinate dose from 200/day to 100/day given
VS as above
- recheck chem 10 (chem 7 + ca/mg/phos) in 3d
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 80 mg PO HS
4. Citalopram 20 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Losartan Potassium 25 mg PO DAILY
9. Docusate Sodium 100 mg PO DAILY
10. Hydrochlorothiazide 25 mg PO DAILY
11. Milk of Magnesia 30 mL PO Q6H:PRN indigestion
12. Bisacodyl 10 mg PR QHS:PRN constipation
13. Lactobacillus acidoph-L. bifid 1 billion cell oral daily
14. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 80 mg PO HS
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. Citalopram 20 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Milk of Magnesia 30 mL PO Q6H:PRN indigestion
9. Omeprazole 20 mg PO DAILY
10. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN cough
11. Lactobacillus acidoph-L. bifid 1 billion cell oral daily
12. Vitamin D 1 home dose PO DAILY
13. Levofloxacin 750 mg PO DAILY Duration: 8 Days
Last day ___
14. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
-healthcare associated pneumonia
-acute renal failure
-___
SECONDARY
-Leukocytosis
-Hypotension
-Hyperglycemia
-Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were treated at ___ for a pneumonia (lung infection).
Because of this infection, you developed low blood pressures and
experienced some transient damage to your kidneys and heart.
These abnormalities were only mild and returned to normal with
treatment of your lung infection and improvement in your blood
pressures.
You also had some evidence of trace blood in your stools at your
nursing facility. You should follow this up with your primary
care provider to get appropriate follow-up testing for this.
Please see your appointments and medications below.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10411588-DS-16 | 10,411,588 | 25,539,554 | DS | 16 | 2124-01-07 00:00:00 | 2124-01-09 21:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ yo M with PMHx Whipple's disease of CNS
who was transferred to ___ ___ after presenting to an OSH
from
a rehab facility with worsening lethargy. History is obtained
from ___ as pt is unable to provide history (see examination
below) and family is not available.
Pt was recently hospitalized at ___ on the neurology service
from ___ for initiation of CTX 2g q12 to treat CNS T.
___ diagnosed on brain biopsy. He was discharged to rehab
on
___ in stable condition.
Per OMR, Dr. ___ has called ___ daughter ___ on
___
to assess ___ progress at rehab. Per note: "She said that "he
is
talking more" and in complete enough sentences now to refuse to
speak to her because he said it is her fault that he is in a
hospital instead of home." Later in the day, per notes: "E.
called back a couple hours later (3:40 pm) to say that her
sister
told her that he is running a fever and refusing Tylenol." Per
nurse at the facility, pt was not responsive to verbal
stimulation with tachycardia to the 130s and a low grade
temperature of 100. He had had decreased PO intake throughout
the
day. He was then transferred to an OSH ED for further mangement.
At the OSH ED, pt was noted to be "obtunded-squints to deep
sternal rub only". He had a rectal temperature to 102.7 with
sinus tachycardia to the 110s. Labs showed hypernatremia to 145,
troponin 0.06, lactate 1.4 and WBC of 12. NCHCT showed no acute
changes and CXR/UA were unremarkable. (This is per oral report,
labs and imaging were pending at time of transfer on paperwork).
He was given 2L of NS and initiated on vanc/zosyn given concern
pt had a history of a recent Whipple surgery. He was then
transferred to ___ for further management.
At time of assessment, pt was resting comfortably. He tracked me
but would not follow commands or speak, therefore I could not
obtain any additional history.
ROS unable to be obtained due to altered mental status.
Past Medical History:
- Whipple's disease of CNS
- depression
- HLD
- DM
- HTN
- superficial thrombophlebitis (vs. ?DVT)
- MGUS (IgA)
- EtOH abuse
- ?hypercoagulable state
- cataracts
- left shoulder surgery
- OSA (but daughter never called for CPAP appointment)
- Gout
Social History:
___
Family History:
No family history of dementia or movement disorders. No history
of strokes or seizures.
Physical Exam:
Admission Exam:
Vitals: 99.2 113 150/99 20 96% RA
General: Chronically ill-appearing
HEENT: NC/AT, MMM
Neck: Supple. No meningismus.
Pulmonary: CTABL
Cardiac: RRR
Abdomen: Soft, NT/ND
Skin: Hyperpigmentation across shins
+foley
Neurologic:
-Mental Status: Awake, eyes open, tracks examiner. Does not
speak. Does not follow commands. No neglect is appreciated. Does
not mimic.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consentually. Blinks to
threat throughout visual fields.
III, IV, VI: EOMI (assessed by having pt track examiner). Eyes
conjugate.
V: Facial sensation intact to pinprick in all distributions as
indicated by grimacing with each pinprick.
VII: Symmetric grimace.
VIII: Unable to assess hearing, but grossly intact.
IX, X: Unable to assess palate elevation.
XI: Unable to assess.
XII: Tongue protrudes in midline.
-Motor: Decreased bulk throughout. Pt will intermittently flex
RUE and point to the ceiling. Pt does not comply with specific
motor group testing but does move all extremities antigravity.
Paratonia is present throughout. No adventitious movements, such
as tremor, noted. Unable to assess pronator drift, asterixis, or
formal strength.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
-Sensory: Pt grimaced to pinprick in all extremities. Unable to
assess fine touch, proprioception or vibration.
-Coordination: Pt did not comply with this examination.
-Gait: Deferred.
Discharge Exam:
-Mental Status: Awake, eyes open, uses socially appropriate
language to answer questions, such as "I'm fine. Thank you for
asking." However, does not answer all questions, does not answer
questions of orientation. Follows some simple commands midline
and appendicular (closes eyes, moves arms/legs).
-CN: PERRL, 3 to 2 mm, eyes cross midline but full EOM are
difficult to evaluate and patient does not track consistently,
eyes conjugate, face grossly symmetric at rest, tongue midline
-Motor: moves all extremities antigravity and spontaneously, has
motor persistence, paratonia throughout. Tends to keep R arm
elevated, occasionally seems to be picking at something in the
air but denies hallucinations.
-Reflexes: 1+ throughout
-Coordination/Gait: not tested, patient not ambulatory. Able to
sit on side of bed without truncal ataxia.
Pertinent Results:
___ CXR
Limited exam due to low lung volumes. No definite pneumonia.
___ CXR
No significant interval change - low lung volumes and no
definite focal
consolidation to suggest pneumonia.
___ 09:10AM BLOOD ALT-22 AST-24 AlkPhos-99 TotBili-0.5
___ 09:10AM BLOOD cTropnT-<0.01
Brief Hospital Course:
Mr. ___ is a ___ yo M with PMHx CNS (Brain) Whipple's disease
who presented with SIRS (tachycardia, fever, leukocytosis),
obtunded. UA suggestive of UTI but urine cultures negative (was
pre-treated with antibiotics here, UA and urine cx from OSH
negative). Blood cultures negative. Had loose stools, CDiff
negative. Treated for presumptive UTI with 7 days of Bactrim.
Continues on ceftriaxone for CNS Whipple's disease.
# CNS (Brain) Whipple's
- Ceftriaxone 2g IV BID ___ to ___
- ALT mildly elevated but resolved during admission
- WBC was slighly low but ___ was normal, diff was normal.
Subsequent ___ checks showed normal WBC.
- s/p bactrim DS 1 tab po BID for UTI for 7 days ___ to ___
- doxycycline 100 mg BID and hydroxychloroquine 200 mg q8h
started ___, for lifelong therapy
# SIRS, presumptive UTI
- s/p bactrim for UTI
- DO NOT place foley
- blood cultures negative
- repeat CXR - no pna
- CDiff negative
# Thrombocytopenia
- new since last admission - discontinued SQH - plt count
improved
- T4 score of 5, concern for heparin-induced thrombocytopenia
but Hep-dependent Ab negative
- unlikely to be due to ceftriaxone, since plt count improved
off of heparin and ctx continued unchanged
# T2DM
- metformin held initially, then restarted
- NPH BID
# Gout: Continue allopurinol
# Depression: Continue Celexa
TRANSITIONAL ISSUES:
- If patient is persistently not eating/drinking well or has to
be treated repeatedly for dehydration with IV fluids, then PEG
tube should be considered to maintain nutrition. As doxycycline
cannot be crushed he was ordered for liquid form.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Escitalopram Oxalate 5 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Thiamine 100 mg PO DAILY
5. CeftriaXONE 2 gm IV Q12H
6. 70/30 15 Units Breakfast
70/30 10 Units Dinner
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Escitalopram Oxalate 5 mg PO DAILY
RX *escitalopram oxalate 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
4. ___ Bed
5. Hoyer Lift
6. Wheelchair
7. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Chewable Multi Vitamin] 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
8. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
9. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 50 mg/5 mL 10 ml by mouth Twice a day Disp
#*1000 Milliliter Milliliter Refills:*0
10. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*0
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 17 g by mouth daily Disp
#*30 Packet Refills:*0
12. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
13. Hydroxychloroquine Sulfate 200 mg PO Q8H
RX *hydroxychloroquine 200 mg 1 tablet(s) by mouth Every 8 hours
Disp #*90 Tablet Refills:*3
14. NPH 12 Units Breakfast
NPH 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro [Humalog] 100 unit/mL AS DIR Up to 8 Units
QID per sliding scale Disp #*1 Cartridge Refills:*0
RX *insulin NPH human recomb [Humulin N] 100 unit/mL AS DIR 12
Units before BKFT; 4 Units before BED; Disp #*1 Vial Refills:*0
15. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth Twice a day Disp #*60
Tablet Refills:*0
16. doxycycline calcium 100 mg oral BID
Please dispense quantity sufficient for month supply. Dose is
100mg po BID.
RX *doxycycline calcium [Vibramycin] 50 mg/5 mL 100 mg by mouth
twice daily Refills:*3
Discharge Disposition:
Home With Service
Facility:
___.
Discharge Diagnosis:
CNS Whipple's Disease
UTI
Hypertension
Diabetes
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted with symptoms of fevers, dehydration,
decreased food intake, and lethargy. You were found to have a
UTI and have been treated with antibiotics. You will continue on
ceftriaxone for your CNS (Brain) Whipple's disease. You will
follow up with infectious disease and your neurologist as an
outpatient.
You were found to have elevated blood pressure in the hospital
and were started on a medication for blood pressure.
Followup Instructions:
___
|
10411588-DS-17 | 10,411,588 | 23,766,173 | DS | 17 | 2126-04-28 00:00:00 | 2126-05-02 14:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute cholecystitis
Major Surgical or Invasive Procedure:
___ Procedures:
___ - US-guided transhepatic cholecystostomy tube
History of Present Illness:
___ with dementia, ___'s disease, DM2, anemia, hyponatremia
who is presenting as a transfer from ___ with
gallbladder wall distention in the setting of sepsis with
concern for cholcystitis source. He was complaining of weakness
to family yesterday in addition to RUQ abdominal pain. He was
agitated at the outside hospital and received 2mg Ativan with
subsequent somnolence, but maintaining his airway. He was found
to be febrile at OSH and given Zosyn and IV fluids and
transferred here for concerns of cholecystitis on US. He is
unable to provide further history due to somnolence on arrival.
He had a desat to 89% en route and was put on 2L NC without
further desaturations.
Past Medical History:
Past Medical History: As above. Dementia, type 2 NIIDM,
whipple's disease, prior ? TIA on monoplatelet therapy since.
Past Surgical History:
- Prior brain biopsy
- No abdominal surgeries.
Social History:
___
Family History:
No family history of dementia or movement disorders. No history
of strokes or seizures.
Physical Exam:
Admission Physical Exam:
===================
Vitals: 97.4, 110, 124/92, 16, 98% NC
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: softly distended, timpanitic on percussion with guarding on
RIUQ to deep palpation. Appreciate what seems to be distended
gallbladder on subcostal margin. No evidence of hernias
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
===================
VS: 98.2 74 147 / 86 2097 RA FBG 141
GEN: NAD
HEENT: MMM, PERRL, EOMI
CV: RRR
PULM: no respiratory distress, lungs CTAB
ABD: soft, NT/min distended, per chole drain in place in RUQ
EXT: WWP
Pertinent Results:
IMAGING:
=======
___: CT Abdomen/Pelvis:
1. Inflammation in the right upper quadrant centered around the
distended
gallbladder containing sludge with surrounding fat stranding and
pericholecystic fluid, concerning for acute cholecystitis.
2. There is inflammatory change extending into the adjacent
transverse colon which has a thickened and edematous wall, and
into the adjacent duodenum, which has a 5.7 cm fluid collection
in the lateral wall.
___: CT Head:
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no large territory infarct or intracranial
hemorrhage.
2. Additional findings as described above.
___: CXR:
Low lung volumes with bibasilar atelectasis. No new focal
consolidation.
___: GB Drainage Procedure:
Successful US-guided placement of ___ pigtail catheter into
the
gallbladder. Samples was sent for microbiology evaluation.
ADMISSION LABS:
==============
___ 07:16AM ___ TEMP-38.0 PO2-58* PCO2-40 PH-7.40
TOTAL CO2-26 BASE XS-0
___ 07:16AM GLUCOSE-185* LACTATE-1.7
___ 07:16AM freeCa-1.17
___ 06:53AM GLUCOSE-183* UREA N-12 CREAT-0.8 SODIUM-139
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-15
___ 06:53AM CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-1.6
___ 06:53AM WBC-23.9* RBC-4.04* HGB-12.7* HCT-38.7*
MCV-96 MCH-31.4 MCHC-32.8 RDW-11.8 RDWSD-41.1
___ 06:53AM NEUTS-86.9* LYMPHS-3.4* MONOS-8.5 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-20.78* AbsLymp-0.82*
AbsMono-2.03* AbsEos-0.00* AbsBaso-0.03
___ 06:53AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 06:53AM PLT SMR-NORMAL PLT COUNT-220
___ 06:53AM ___ PTT-25.3 ___
___ 02:53AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:53AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-1000* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:53AM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 02:53AM URINE HYALINE-3*
___ 12:09AM ___ PO2-58* PCO2-36 PH-7.43 TOTAL CO2-25
BASE XS-0
___ 12:09AM LACTATE-2.1* K+-3.9
___ 11:57PM GLUCOSE-240* UREA N-12 CREAT-0.8 SODIUM-134*
POTASSIUM-7.0* CHLORIDE-98 TOTAL CO2-23 ANION GAP-13
___ 11:57PM ALT(SGPT)-42* AST(SGOT)-77* CK(CPK)-81 ALK
PHOS-73 TOT BILI-0.6
___ 11:57PM LIPASE-15
___ 11:57PM CK-MB-<1 cTropnT-<0.01
___ 11:57PM ALBUMIN-3.1* CALCIUM-8.7 MAGNESIUM-1.6
___ 11:57PM WBC-26.8*# RBC-4.17* HGB-13.3* HCT-39.7*
MCV-95 MCH-31.9 MCHC-33.5 RDW-11.8 RDWSD-41.2
___ 11:57PM NEUTS-87.2* LYMPHS-2.6* MONOS-9.1 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-23.32*# AbsLymp-0.70*
AbsMono-2.43* AbsEos-0.00* AbsBaso-0.03
___ 11:57PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-1+* MACROCYT-1+* MICROCYT-NORMAL POLYCHROM-1+*
OVALOCYT-1+*
___ 11:57PM PLT SMR-NORMAL PLT COUNT-244
___ 11:57PM ___ PTT-25.0 ___
DISCHARGE LABS:
==============
___ 05:53AM BLOOD WBC-6.3# RBC-3.28* Hgb-10.5* Hct-32.0*
MCV-98 MCH-32.0 MCHC-32.8 RDW-11.9 RDWSD-42.8 Plt ___
___ 05:53AM BLOOD Glucose-124* UreaN-11 Creat-0.7 Na-144
K-4.0 Cl-105 HCO3-28 AnGap-11
___ 12:53AM BLOOD ALT-88* AST-68* LD(LDH)-174 AlkPhos-85
TotBili-0.4
___ 05:53AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.2
___ 06:16AM BLOOD %HbA1c-7.3* eAG-163*
Brief Hospital Course:
The patient was admitted to ___ after presenting from an OSH
to ___ ED with DKA decompensated due to acute cholecystitis.
The patient was admitted to the SICU for management of his DKA,
and in the interim, was given bowel rest/decompression with NG
tube, IV hydration, and broad spectrum IV antibiotic therapy was
provided. On ___, the patient had a percutaneous
cholecystostomy drain was place by interventional radiology. On
___, the patient was transferred to the surgical floor,
which is where he spent the remainder of his stay.
On ___, the patient passed a bedside swallow study and he
tolerated a regular diet. On ___, the patient was seen by
physical therapy, who recommended either rehab or, since the
family said the patient is provided with ___ care, that he may
be discharged with ___ services. The patient was then deemed
surgically cleared and ready for discharge home with ___
services.
At the time of discharge the patient was tolerating a regular
diet, is incontinent at baseline, requires assistance when
transferring to a chair or wheelchair, and his pain is well
controlled. The patient and his daughter received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Hydroxychloroquine Sulfate 200 mg PO TID
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Vibramycin (doxycycline calcium;<br>doxycycline
hyclate;<br>doxycycline monohydrate) 50 mg/5 mL oral BID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Take this medication through ___.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*26 Tablet Refills:*0
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*22 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Hydroxychloroquine Sulfate 200 mg PO TID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. HELD- Vibramycin (doxycycline calcium;<br>doxycycline
hyclate;<br>doxycycline monohydrate) 50 mg/5 mL oral BID This
medication was held. Do not restart Vibramycin until you have
completed your course of Augmentin. Resume this antibiotic
beginning on ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetic ketoacidosis
Acute cholecystitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Dear Mr. ___,
You had symptoms of weakness, fevers, right upper quadrant
abdominal pain, abdominal distention and worsening mental
status. You had hyperglycemia and an elevated white blood cell
count, indicative of infection. You were admitted to the ICU for
an insulin drip and IV antibiotics. Interventional radiology
performed a percutaneous cholecystostomy at the bedside to
decompress your gallbladder. You tolerated this well, and your
blood sugars and electrolytes normalized. You were then
transferred out to the general surgical floor. You are now
stable and doing well. You are tolerating a regular diet and
your lab work and vital signs are stable. You are medically
clear for discharge home to continue your recovery. Please note
the following:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and gently wash drain site.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10411588-DS-19 | 10,411,588 | 25,893,228 | DS | 19 | 2126-06-07 00:00:00 | 2126-06-15 16:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Percutaneous cholecystostomy tube dislodgement
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy
History of Present Illness:
___ w/ PMHx notable for dementia, ___ disease, DM2, and
cholecystitis treated with percutaneous cholecystostomy in
___ now presents for evaluation of a dislodged drain.
Since being discharged from hospital on ___, pt has been seen
in clinic for routine follow-up and has had improvement in
abdominal pain and no fevers. He underwent a tube cholangiogram
on ___ which demonstrated good positioning of the tube but no
filling of the cystic duct or small bowel. He was undergoing
workup for planned elective lap chole with Dr. ___ on ___
but in the interval noted that his tube had become slightly
dislodged which prompted him to seek medical evaluation. Upon
arrival to ___ ED ___ pt was noted to have no abnormalities
with regards to labs. Imaging included an US which was
unrevealing as well as a CT scan which demonstrated appropriate
placement of the tube with decompression of the gallbladder.
Surgery is now consulted regarding additional tube management
since it has migrated further since arrival to the ED and
patient's family would prefer to undergo surgery at earlier time
point due to difficulties managing the tube.
Past Medical History:
- ___'s disease of CNS
- Cholecystitis s/p perc chole placement ___
- depression
- HLD
- DM
- HTN
- superficial thrombophlebitis (vs. ?DVT)
- prior ? TIA on monoplatelet therapy
- MGUS (IgA)
- EtOH abuse
- ?hypercoagulable state
- cataracts
- left shoulder surgery
- OSA (but daughter never called for CPAP appointment)
- Gout
Social History:
___
Family History:
No family history of dementia or movement disorders. No history
of strokes or seizures
Physical Exam:
Admission Physical Exam:
99.6 83 143/74 17 100RA
GEN: A&Ox2, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: softly, NT, ND, perc drain not in stat lock and appears to
have migrated. drain is to gravity and not productive of bilious
output.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
97.3, 168 / 82, 71, 18, 100% Ra
GEN: A&Ox2, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: softly, NT, ND,
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 05:55AM BLOOD WBC-4.5 RBC-3.52* Hgb-11.2* Hct-34.1*
MCV-97 MCH-31.8 MCHC-32.8 RDW-12.1 RDWSD-42.8 Plt ___
___ 06:10AM BLOOD WBC-4.9 RBC-4.09* Hgb-13.5* Hct-40.0
MCV-98 MCH-33.0* MCHC-33.8 RDW-12.2 RDWSD-43.4 Plt ___
___ 04:22PM BLOOD WBC-7.8 RBC-3.91* Hgb-12.6* Hct-38.0*
MCV-97 MCH-32.2* MCHC-33.2 RDW-12.2 RDWSD-43.8 Plt ___
___ 06:10AM BLOOD ___ PTT-28.4 ___
___ 10:03PM BLOOD ___ PTT-26.7 ___
___ 05:55AM BLOOD Glucose-196* UreaN-5* Creat-0.7 Na-143
K-4.0 Cl-104 HCO3-26 AnGap-13
___ 06:10AM BLOOD Glucose-141* UreaN-8 Creat-0.6 Na-144
K-4.1 Cl-101 HCO3-27 AnGap-16
___ 04:22PM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-138
K-4.5 Cl-97 HCO3-21* AnGap-20*
___ 06:10AM BLOOD ALT-25 AST-19 AlkPhos-93 TotBili-0.4
___ 04:22PM BLOOD ALT-25 AST-17 AlkPhos-89 TotBili-0.2
___ 05:55AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.8
___ 06:10AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.8
___ T-Tube cholangiogram:
IMPRESSION:
1. The tip of the cholecystostomy tube is in the gallbladder and
there is no evidence of leak.
2. The contrast remained in the gallbladder without
opacification of the
biliary ducts or the cystic duct.
___ Gallbladder US:
The previously placed cholecystostomy tube is seen within the
subcutaneous
tissues overlying the liver, however it cannot be tracked to the
level of the gallbladder nor is the tip visualized. CT may be
necessary for further
evaluation of cholecystostomy tube placement.
Brief Hospital Course:
___ is a ___ yo M admitted to the Acute Care Surgery
Service with concern for dislodgement of percutaneous
cholecytsotmy tube placed in ___. Due to his
underlying diagnosis of demenisia he removed the tube several
time and therefore the decision to proceed with cholecystostomy
was made. On ___ the patient was taken to the operating
room and underwent laparoscopic cholecystostomy. After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating a regular diet , on IV fluids, and IV tylenol for
pain control. The patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was seen and evaluated by physical
therapy who recommended discharge to home with lift. The patient
was discharged to home with services. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Hydroxychloroquine Sulfate 200 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO BID
4. glimepiride 4 mg oral DAILY
5. Vibramycin (doxycycline calcium;<br>doxycycline
hyclate;<br>doxycycline monohydrate) 50 mg oral BID
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Finasteride 5 mg PO DAILY
follow up with primary care to determine ongoing need.
RX *finasteride 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. Tamsulosin 0.4 mg PO QHS
follow up with primary care to determine ongoing need.
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
6. Aspirin 81 mg PO DAILY
7. glimepiride 4 mg oral DAILY
8. Hydroxychloroquine Sulfate 200 mg PO BID
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Vibramycin (doxycycline calcium;<br>doxycycline
hyclate;<br>doxycycline monohydrate) 50 mg oral BID
11.___ Lift
Diagnosis: Gait instability, Deconditioning, Acute Cholecystitis
Prognosis: Good
Length of need: ___ year
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with drainage around your gallbladder drain. You had imaging
that showed the drain appeared to be in the correct place. Given
your symptoms, it was decided that now would be an appropriate
time to have your gallbladder removed. On ___ you were
taken to the operating room and had your gallbladder removed
laparoscopically. You are now doing better, tolerating a regular
diet and ready to be discharged to continue your recovery from
surgery.
Please note the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10411654-DS-5 | 10,411,654 | 26,549,810 | DS | 5 | 2134-06-14 00:00:00 | 2134-06-16 09:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Meperidine
Attending: ___
Chief Complaint:
right upper quadrant abdominal pain
Major Surgical or Invasive Procedure:
___ ERCP
___ Laparoscopic cholecystectomy
History of Present Illness:
HPI: ___ acute onset RUQ pain since 1800 day of presentation
progressively worse, now radiating to back. First episode.
Nausea, no emesis. Denies fevers or chills. Denies unintentional
weight loss, jaundice, scleral icterus, tea-colored urine, pale
stools.
History notable for similar presentation ___ with CT notable
for
hepatic flexure diverticula which was conservatively managed.
Follow-up colonoscopy ___ (OSH) demonstrating scattered
sigmoid, hepatic flexure, and proximal transverse colon
diverticulosis with few everted diverticula. 4 mm sessile polyp
in proximal ascending colon. Polypectomy performed with cold
biopsy forceps. Pathology consistent with adenoma. No interval
episodes.
Past Medical History:
PMH: Diverticulitis, MDD, BCC (back), Chronic Constipation,
Gastritis, Esophagitis
PSH: Denies
Social History:
___
Family History:
Denies liver of gallbladder disease. Mother: DM. Father:
Stomach CA, CVA
Physical Exam:
On admission:
VS: T 98.9, HR 72, BP 111/65, RR 15, SaO2 100%rm air
GEN: NAD, A/Ox3
HEENT: EOMI, no scleral icterus
CV: RRR, no M/R/G
PULM: CTAB
BACK: No CVAT
ABD: soft, no surgical scars, RUQ tenderness, +positive ___
sign.
EXT: WWP, distal pulses intact
DERM: no jaundice
Pertinent Results:
___ GALLBLADDER US
1. Obstructing 1.2 cm distal CBD stone with dilatation of the
CBD to 6 mm.
2. No pancreatic ductal and no intrahepatic biliary dilatation.
3. No gallstones but gallbladder wall edema, distention and
pericholecystic fluid. HIDA might be considered, if clinically
indicated.
___ 06:40AM BLOOD WBC-3.0*# RBC-3.89* Hgb-12.1 Hct-36.2
MCV-93 MCH-31.1 MCHC-33.4 RDW-12.6 Plt ___
___ 01:30AM BLOOD WBC-6.1 RBC-4.62 Hgb-13.8 Hct-43.0
MCV-93# MCH-29.9 MCHC-32.2# RDW-12.2 Plt ___
___ 01:30AM BLOOD Neuts-75.6* Lymphs-17.3* Monos-4.7
Eos-1.4 Baso-1.0
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD ___
___ 06:40AM BLOOD Glucose-103* UreaN-5* Creat-0.5 Na-141
K-3.8 Cl-107 HCO3-27 AnGap-11
___ 01:30AM BLOOD Glucose-123* UreaN-9 Creat-0.7 Na-138
K-3.6 Cl-102 HCO3-28 AnGap-12
___ 06:40AM BLOOD ALT-12 AST-12 AlkPhos-37 Amylase-36
TotBili-0.3
___ 01:30AM BLOOD ALT-16 AST-21 AlkPhos-51 TotBili-0.3
___ 01:30AM BLOOD Lipase-39
___ 06:40AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9
Brief Hospital Course:
Ms. ___ was admitted on ___ under the Acute Care Surgical
Service for management of her acute cholecystitis. She was kept
NPO and given intravenous fluids for hydration. She was started
empirically on intravenous unasyn. On the day of admission she
underwent ERCP as ultrasound findings were concerning for distal
choledocolithiasis. A single diverticulum with small opening was
found at the major papilla but no stone and a normal biliary
tree. On ___ she remained nontender with normal LFT's and
lipase and was taken to the operating room for a laparoscopic
cholecystectomy.
Her operative course was stable with minimal blood loss. She
was extubated after the procedure and monitored in the recovery
room. On POD #1, she was started on a regular diet. She was
transitioned to oral analgesia for management of the surgical
pain.
Her vital signs have been stable and she has been afebrile. She
is preparing for discharge home with follow-up in the acute care
clinic.
Medications on Admission:
Spirolactone 200, Magnesium Oxide 300 qHS
Discharge Medications:
1. spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*25 Tablet(s)* Refills:*0*
5. magnesium oxide-Mg AA chelate 300 mg Capsule Sig: One (1)
Capsule PO at bedtime.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
7. ketorolac 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 5 days: please take with food.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10412446-DS-10 | 10,412,446 | 27,886,914 | DS | 10 | 2116-10-06 00:00:00 | 2116-10-06 10:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Bloody stools, lightheadedness, vomiting
Major Surgical or Invasive Procedure:
ERCP with removal of axios stent
History of Present Illness:
Mr. ___ is a ___ male with a past medical
history of atrial fibrillation on xarelto, sCHF (EF 35-40%),
CAD, PVD on Plavix, COPD, and known pancreatic cyst who presents
with melena. He was admitted to ___ from ___ - ___ with
RUQ
abdominal pain and jaundice. He was found on imaging at the OSH
to have an enlarging pancreatic cyst causing compression of the
biliary tree. He was empirically covered with Cipro/Flagyl; but
clinically without overt signs of cholangitis, sepsis, or
hemodynamic instability. He had an EUS with placement of
cystgastrostomy on ___ and was discharged in stable
condition.
Patient states that after that time, he had difficulty taking in
adequate PO but has been making progress. On ___ he underwent
an
angiogram of his left leg at ___ with hid vascular
surgeon,
Dr. ___. He reports that he had laser treatment and a
stent placed and was discharged home on Plavix 75mg in addition
to the Xeralto and ASA 81mg that he takes normally. On ___, he
had a full lunch and afterwards felt nauseous. He had dry
heaves
then vomited bilious material. About one hour later, he noted
that he had black bowel movement where the toilet water was deep
color of red. This occurred 2 additional times and was
associated with significant fatigue, lightheadedness and
dizziness with movement. He was taken to an outside hospital
where he was noted to have hemoglobin dropped to 7.2. Patient
was
transfused 1 unit and transferred to ___ given his previous
endoscopies here.
Initial vitals in the ER: 95.9 80 112/63 16 99% RA. He
received 1 unit PRBCs and was seen by ERCP, ___, and GI consult
teams before being transferred to the ___. On arrival,
he
notes being hungry, slightly short of breath, but denies having
abdominal pain, fevers, leg pain, nausea, or vomiting.
Re: CHF - no increased edema, weight gain, or difficulty
breathing recently
Re: A fib, no current palpitations or chest pain
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Atrial fibrillation on xarelto
sCHF with LVEF 35%
CAD s/p MI ___ years ago
PVD on Plavix, s/p b/l femoral artery stents
COPD
Pancreatic cyst
HTN
HLD
Diverticulosis
Appendectomy
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization. No family history of
malignancy apart from father with lung cancer and was a heavy
smoker
Physical Exam:
DISCHARGE EXAM:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular rate; normal perfusion, no appreciable JVD
RESP: Symmetric breathing pattern with no stridor. Breathing is
non-labored
GI: Abdomen soft, non-tender, non-distended, no
hepatosplenomegaly appreciated.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, normal muscle bulk and tone
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: normal thought content, logical thought process,
appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 06:36PM BLOOD WBC-16.2*# RBC-2.58*# Hgb-7.7*#
Hct-23.3*# MCV-90 MCH-29.8 MCHC-33.0 RDW-14.3 RDWSD-46.8* Plt
___
___ 06:36PM BLOOD Neuts-69.6 ___ Monos-6.7 Eos-1.8
Baso-0.2 Im ___ AbsNeut-11.26* AbsLymp-3.42 AbsMono-1.08*
AbsEos-0.29 AbsBaso-0.04
___ 06:36PM BLOOD ___ PTT-30.4 ___
___ 06:36PM BLOOD Glucose-92 UreaN-36* Creat-1.0 Na-138
K-6.3* Cl-100 HCO3-23 AnGap-15
___ 05:42AM BLOOD Calcium-8.7 Phos-4.8* Mg-2.1
DISCHARGE LABS:
___ 06:12AM BLOOD WBC-9.2 RBC-3.27* Hgb-9.9* Hct-30.0*
MCV-92 MCH-30.3 MCHC-33.0 RDW-14.6 RDWSD-48.3* Plt ___
___ 06:12AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
___ 06:12AM BLOOD ALT-PND AST-PND AlkPhos-PND TotBili-PND
___ 06:12AM BLOOD Albumin-PND Calcium-PND Mg-PND
IMAGING:
========
___ Cta Abd & Pelvis
1. Status post cyst gastrostomy. The cyst within the region of
the pancreatic head is unchanged in size measuring up to 4.0 cm,
however there is a focus of arterial hyperenhancement within the
cyst, which follows blood pool on all phases, likely
representing
a small pseudoaneurysm. No definite feeding vessel and no
pooling
of contrast to suggest active extravasation.
2. Persistent mild intrahepatic biliary dilatation. No
extrahepatic biliary
dilatation, however there is enhancement of the common bile duct
wall, which may be reactive in nature, but should be correlated
clinically for any signs of cholangitis.
3. Additional cystic lesions within the pancreatic neck
measuring
up to 8 mm,
possibly representing side-branch IPMNs.
4. Chronic appearing focal dissection involving the proximal
left
common iliac artery.
___ MESENTERIC ANGIOGRAM:
1. Common hepatic arteriogram does not demonstrate any focus of
active
bleeding or pseudoaneurysm.
2. Initial superior mesenteric arteriogram demonstrates no
definite active
bleeding, pseudoaneurysm or arteriovenous fistula. Further
interrogation of
an IPDA branch of the SMA also demonstrates no abnormality.
3. Cone beam CTs of the gastroduodenal artery and the SMA
demonstrate no
evidence of extravasation, pseudoaneurysm or arteriovenous
fistula.
___ CT a/p w/Contrast
1. Patient status post cyst gastrostomy with possible slight
retraction of the stent into the pancreatic head cyst.
PROCEDURES:
===========
ERCP ___:
Impression:
Both the plastic and the Axios stent could not be visualized
endoscopically.
However, under fluoroscopy, the axios stent was visualised.
However, the plastic stent could not be visualized
fluoroscopically.
Otherwise normal EGD to third part of the duodenum
Recommendations:
Clear liquid diet when awake, then advance diet as tolerated.
If any fever, worsening abdominal pain, or post procedure
symptoms, please call the advanced endoscopy fellow on call
___/ pager ___.
Repeat CT scan to evaluate stent migration
ERCP ___:
Impression:
Normal mucosa in the esophagus
Normal mucosa in the stomach
The Axios lumen apposing metal stent was identified in the
duodenal bulb. It was removed successfully with a rat tooth
forceps under endoscopic and fluoroscopic guidance with minimal
oozing at the end of the case.
Otherwise normal EGD to third part of the duodenum
Recommendations:
Clear liquid diet today and advance as tolerated tomorrow if
stable.
Trend CBC
Follow-up with primary gastroenterologist Dr. ___ in
3 weeks
If any fever, worsening abdominal pain, or post procedure
symptoms, please call the advanced endoscopy fellow on call
___/ pager ___.
___ resume anticoagulants in 48 hours
Brief Hospital Course:
Mr. ___ is a ___ male with a past medical
history of atrial fibrillation on xarelto, sCHF (EF 35-40%),
CAD, PVD on Plavix, COPD, and known pancreatic cyst who presents
with melena, likely bleeding from ___
pseudocyst cavity.
# Anemia secondary to acute blood loss, upper GI bleeding
# Pseudo aneurysm in pancreatic cyst
Likely precipitated by his vascular surgeon placing him on
Plavix ___ after angiography and stent placement which was in
addition to his Xarelto and Aspirin. ___ performed mesenteric
arteriogram ___ which did not show any active bleeding or
pseudoaneurysm. He had no further episodes of melena or
hematochezia since admission and Hb remained stable in the ___
range. Pt underwent ERCP x2 (first unsuccessful) with
successful axios stent removal on ___. He tolerated this
procedure well with minimal post-procedural discomfort
afterwards.
# Chronic HFrEF:
He has a known baseline LVEF of 35%. Lasix and spironolactone
were held initially given c/f GIB. They were restarted once pt
was stable. Home carvedilol decreased to 6.25mg BID given
persistent low BP's while hospitalized. Continued home low dose
Lisinopril.
# CAD
# Atrial fibrillation - Cont digoxin and half-dose carvedilol.
Home rivaroxaban was held for axios stent removal. Plan to
restart 48 hours post-procedure (on ___. He was continued on
home aspirin.
# PVD - Spoke with Dr. ___ and covering MD said it was
___ to hold Plavix for axios stent removal. He will restart this
48 hours post-procedure (on ___
TRANSITIONAL ISSUES:
====================
# Right renal mass - radiology attending on ___ said this is a
new finding. The area used to look cystic, then was not
present, and now reappears and has arterial enhancement (5mm).
DDx is mass vs. small pseudoaneurysm. MRI of the area when
other issues have resolved was recommended, patient informed.
# Pancreatic masses, possible IPMNs, needs to be followed as an
outpatient.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Digoxin 0.25 mg PO DAILY
4. Ferrous GLUCONATE 324 mg PO DAILY
5. Furosemide 80 mg PO DAILY
6. Lisinopril 5 mg PO BID
7. Rivaroxaban 20 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
9. dexlansoprazole 60 mg oral DAILY
10. ezetimibe-simvastatin ___ mg oral QHS
11. Mag 64 (magnesium chloride) 64 mg oral DAILY
12. Sildenafil 50 mg PO DAILY:PRN activity
13. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Carvedilol 6.25 mg PO BID
This was decreased to ___ your regular home dose given low BP's
while hospitalized
2. Aspirin 81 mg PO DAILY
3. dexlansoprazole 60 mg oral DAILY
4. Digoxin 0.25 mg PO DAILY
5. ezetimibe-simvastatin ___ mg oral QHS
6. Ferrous GLUCONATE 324 mg PO DAILY
7. Furosemide 80 mg PO DAILY
8. Lisinopril 5 mg PO BID
9. Mag 64 (magnesium chloride) 64 mg oral DAILY
10. Sildenafil 50 mg PO DAILY:PRN activity
11. Spironolactone 25 mg PO DAILY
12. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until ___
13. HELD- Rivaroxaban 20 mg PO DAILY This medication was held.
Do not restart Rivaroxaban until ___
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic pseudocyst
GI bleeding
Atrial fibrillation
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with vomiting and bloody bowel
movements, associated with fatigue, lightheadedness and
dizziness. The interventional radiology and gastroenterology
teams evaluated you and felt that the bleeding may have been
some oozing from your pancreatic cyst. You underwent an
angiogram which did not show any evidence of ongoing bleeding.
You underwent 2 ERCP's and your stent draining the cyst was
successfully removed on the second attempt. You tolerated this
procedure well with no obvious immediate complications.
Please return if you have any lightheadedness, passing out,
worsening abdominal pain, or notice any recurrent blood in your
stools.
It was a pleasure taking care of you at ___ ___
___.
Followup Instructions:
___
|
10412483-DS-18 | 10,412,483 | 27,477,495 | DS | 18 | 2132-11-27 00:00:00 | 2132-11-27 16:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ male with history of CHF, HTN, Afib on Eliquis,
chronic LBBB, aortic stenosis, falls, and dementia who presents
to the ___ ED for evaluation of right hip pain s/p fall from
standing. Reports standing up from the couch to go to bed and he
fall to the right directly on his hip. He developed immediate
hip pain and could not stand up. His pain was ___ at the hip.
He was able to call ___ by pressing his alert button and was
soon found by a at his assisted living facility. He was then
brought to the ED for evaluation. He is unsure the
circumstances of his fall, but does report history of multiple
falls due to poor balance. He denies striking his head or loss
of consciousness. He has some mild neck pain. Denies pain
location denies having any tingling or numbness. He denies any
chest pain, shortness of breath, nausea, vomiting, diarrhea,
dysuria.
Of note patient has had multiple falls in the past. He was
hospitalized 6 times in ___ year for falls, most recently in
___. Had multiple fractures related to falls. Falls thought
to be secondary to orthostatic hypotension and he was initiated
on Midodrine and fludracortisone. He did well for over ___ year
and
has not had significant falls or hospitalizations.
Approximately one month ago he underwent at ___ for lower
extremity edema workup and was found to have severe AS. He
established care with Dr. ___. He was initated on Lasix
40mg on ___ and his fludracortisone was stopped on ___.
In the ED, initial vitals were: T96.9, HR 76, BP 186/82, RR 18,
O2 95% 4L NC.
Exam notable for severe pain over R hip.
Labs notable for BNP of 2782. Hemoglobin 12.6->12.4->12.___/P ___: 1. A 4.7 cm right inguinal hematoma
is noted as well as extensive hemorrhage in the extraperitoneal
space anterior to the bladder.
2. Comminuted fracture of the right superior pubic ramus as
well as contour irregularity of the right inferior pubic ramus
compatible with fracture.
3. Fracture of the right sacral ala.
Patient seen by Ortho trauma who recommended ___
management and protected weight bearing as tolerated, bilateral
lower extremities.
He received IV morphine and Lasix 20mg IV.
On the floor, patient confirmed above history. He reports
extreme pain in his right hip with any changes in position. He
is very upset he is in the hospital. He feels slightly short of
breath, but denies any chest discomfort.
Past Medical History:
Acute on chronic diastolic heart failure
Afib on Eliquis
Aortic Stenosis
Left Bundle Branch Block
Hypertension
Orthostatic hypotension
Early dementia/confusion
Depression
BPH
Social History:
___
Family History:
No family history of stroke. Father with CAD.
Physical Exam:
DISCHARGE:
___ 0804 Temp: 97.3 AdultAxillary BP: 132/69 R Lying HR: 63
RR: 16 O2 sat: 95% O2 delivery: 2L Nc
-Weight: 62.2 137.13 Bed weight -> increased from ___
I/Os: 24h -1.3L
General: well appearing, in NAD
HEENT: AT/NC. PERRLA. Moist mucus membranes.
Neck: Supple. No LAD.
Lungs: Improved bibasilar crackles, no wheeze/rales
CV: (+) holosytolic murmur loudest at LUSB, regular rate and
rhythm.
GI: soft, ND/NT, (+)BS
Ext: No pitting edema bilaterally, (+) palpable distal pulses
bilaterally
Neuro: Alert and oriented to person, time, not place. CNs ___
diffusely in tact, moves all extremities spontaneously
Pertinent Results:
ADMISSION:
___ 04:50AM ___
___
___ 04:50AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 04:50AM ___
DISCHARGE:
___ 07:48AM BLOOD ___
___ Plt ___
___ 07:48AM BLOOD ___
___
IMAGING:
-CT A/P ___:
1. A 4.7 cm right inguinal hematoma is noted as well as
extensive hemorrhage in the extraperitoneal space anterior to
the bladder.
2. Comminuted fracture of the right superior pubic ramus as
well as contour irregularity of the right inferior pubic ramus
compatible with fracture.
3. Fracture of the right sacral ala.
-CT ___ ___:
1. No acute cervical spine fracture or new malalignment. No
prevertebral fluid.
2. Unchanged minimal ___ anterolisthesis, likely degenerative.
Otherwise, cervical spine alignment is within normal limits.
3. Unchanged moderate multilevel cervical spine degenerative
changes, causing areas of moderate severe spinal canal stenosis
at ___ and multilevel moderate neural foraminal narrowing.
4. Large layering right and small layering left pleural
effusions are partially visualized.
-CTA Pelvis ___:
IMPRESSION:
1. No evidence of active arterial hemorrhage in the pelvis.
2. Mild interval increase in size of the right inguinal
hematoma.
3. Fractures of the right superior and inferior pubic rami and
right sacral ala.
-CXR ___:
IMPRESSION: Interval decrease in size of the right pleural
effusion. No pneumothorax identified.
-TTE ___:
IMPRESSION: Suboptimal image quality. Symmetric LVH with normal
global LV systolic function. Dilated and hypokinetic right
ventricle with evidence of poor RV compliance
("echocardiographic Kussmaul's sign"). Moderate aortic stenosis.
Mild mitral regurgitation. Moderate pulmonary hypertension.
Compared with the prior TTE ___, there is evidence of
significant RV dysfunction. On the other hand, intrinsic LV
function is probably normal and whatever LV dyssynchrony is seen
is likely secondary to RVLV interaction.
-CT Chest with Contrast ___
IMPRESSION:
1. New moderate right and small ___ nonhemorrhagic
pleural
effusions, source unclear.
2. Interval decrease in size and conspicuity of peribronchial
___ nodules in the left lower lobe, likely representing
sequela of infectious or inflammatory insult.
3. Stable peribronchial ___ attenuation in the left
upper lobe, which may represent the residua of prior
infection/inflammation or improving airway mucous inspissation.
4. Stable 3 mm right upper lobe and 1 mm right middle lobe
pulmonary nodules.
Otherwise no new or growing pulmonary nodule.
5. Unchanged numerous densely calcified mediastinal and hilar
lymph nodes suggesting prior granulomatous insult.
6. Punctate nonobstructing right renal calculus.
-TTE ___
There is moderate symmetric left ventricular hypertrophy with a
normal cavity size. There is suboptimal image
quality to assess regional left ventricular function. The
visually estimated left ventricular ejection fraction is
60%. There is no resting left ventricular outflow tract
gradient.
The right ventricular free wall is hypertrophied.
Dilated right ventricular cavity with uninterpretable (but at
least mild) free wall systolic dysfunction. The aortic
sinus diameter is normal for gender. The aortic valve leaflets
are severely thickened. There is moderate aortic
valve stenosis (valve area ___ cm2). There is no aortic
regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. There is moderate
mitral
annular calcification. There is mild [1+]
mitral regurgitation. Due to acoustic shadowing, the severity of
mitral regurgitation could be UNDERestimated.
The tricuspid valve leaflets appear structurally normal. There
is
mild [1+] tricuspid regurgitation. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
CYTOLOGY:
-Pleural Fluid, right side ___:
NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells,
lymphocytes and histiocytes.
Brief Hospital Course:
Summary:
___ ___ male with history pertinent for HFpEF (EF 60%), HTN,
___ on Eliquis, chronic LBBB, aortic stenosis, orthostatic
hypotension, recurrent falls, and dementia who presented to the
ED after a fall found to have pelvic fracture and
intraperitoneal hematoma as well as HFpEF exacerbation
potentially triggered by midodrine.
Acute Issues:
#Fall:
#Aortic stenosis
#Orthostatic hypotension
#Mechanical fall
He describes that he was sitting in a chair and when he stood
upright, he instantly fell. He denied any prodrome or dizziness
prior to the fall. He did not lose consciousness. He called for
medical help while down and was transported to the ED. Of note,
he has a history of prior falls attributed to orthostatic
hypotension and was on midodrine and florinef for one year,
during which time he did not experience any falls. Four days
prior to his fall, his florinef was held due to a recent
diagnosis of aortic stenosis. In addition he was initiated on
Lasix 40 mg x2 weeks prior to his fall. He underwent ___ was
which notable for (+) orthostasis, significant volume overload,
TTE with moderate aortic stenosis. Etiology of his fall was
thought to be multifactorial - mechanical, orthostasis, and
aortic stenosis. His midodrine/florinef were held. He received
IV diuresis. He was evaluated by ___, and was discharged to
rehab.
-Counsel on orthostatic precautions
-Monitor volume status; discharge weight: 62.2 kg (137.13 lb)
#Pelvic fracture:
#Retroperitoneal hemorrhage / right inguinal hematoma
In the setting of fall, patient underwent trauma evaluation with
CT scan showing fracture of the superior and inferior rami of
the right pelvis with right peritoneal hemorrhage and right
inguinal hematoma. Ortho trauma evaluated him in the ED and
determined ___ management would be most appropriate.
His vitals and H/H were trended and he received 1u PRBC on
admission. His apixaban was held in the ED in the setting of
internal bleeding. Apixaban was restarted on ___ after stable
blood counts. He received pain control with tramadol, as he
became encephalopathic with oxycodone.
-Wean pain medications as appropriate
-Please check CBC in x1 week
#Acute on chronic diastolic heart failure exacerbation:
#Acute hypoxic respiratory distress
#Right pleural effusion
Patient presented with evidence of volume overload. Etiology of
heart failure exacerbation thought to be midodrine/florinef and
undertitration of outpatient diuresis. He underwent TTE which
showed moderate AS, EF 60%. Cardiology was consulted, his and he
received IV diuresis with improvement in his volume status. Due
to large right pleural effusion, he underwent thoracentesis was
performed on ___ draining 1.5 L of clear fluid from the pleural
space. He was transitioned to torsemide 10mg daily.
-Discharge weight: 62.2 kg (137.13 lb)
#Toxic metabolic encephalopathy:
#Delirium
Patient with waxing and waning mental status; etiology thought
to be due to ___ delirium vs medication effect in
setting of dementia. ___ negative for infectious etiology,
metabolic etiology. His oxycodone was changed to tramadol. He
was monitored on delirium precautions. He was started on
ramelteon to help with sleep.
-Continue to ___
Chronic Issues:
#Atrial Fibrillation:
CHADSVASC score of 4. In the setting of bleed, his home apixaban
was initially held. It was restarted prior to discharge with
stable Hgb.
#Depression:
He was continued on his home venlafaxine.
Transitional Issues:
[] Held midodrine, fludrocortisone given heart failure
[] Counsel on orthostatic precautions
[] Ortho trauma follow up in ___ weeks - we will check an AP
view of his pelvis while bearing weight
[] CT chest findings ___:
-Stable 3 mm right upper lobe and 1 mm right middle lobe
pulmonary nodules found on CT chest
# ADVANCE CARE PLANNING:
DNR/DNI except in setting of procedure
Name of health care proxy: ___
___ number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lactobacillus combination no.4 unknown oral DAILY
2. Apixaban 2.5 mg PO BID
3. Venlafaxine XR 37.5 mg PO DAILY
4. Docusate Sodium 100 mg PO BID constipation
5. Midodrine 2.5 mg PO BID
6. Atorvastatin 20 mg PO QPM
7. Vitamin D 1000 UNIT PO DAILY
8. Furosemide 40 mg PO DAILY
9. Fludrocortisone Acetate 0.2 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Acetaminophen 1000 mg PO BID
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY
2. Senna 17.2 mg PO BID
3. Torsemide 10 mg PO DAILY
4. TraMADol 50 mg PO BID
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. Acetaminophen 1000 mg PO Q8H
7. lactobacillus combination ___ unit oral DAILY
8. Apixaban 2.5 mg PO BID
9. Atorvastatin 20 mg PO QPM
10. Docusate Sodium 100 mg PO BID constipation
11. Tamsulosin 0.4 mg PO QHS
12. Venlafaxine XR 37.5 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Fludrocortisone Acetate 0.2 mg PO DAILY This
medication was held. Do not restart Fludrocortisone Acetate
until you follow up with your Cardiologist
15. HELD- Midodrine 2.5 mg PO BID This medication was held. Do
not restart Midodrine until you follow up with your Cardiologist
16.Outpatient Lab Work
Please check ___, CBC
Dx: acute on chronic diastolic heart failure ___: ___.31
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Syncope
Pelvic fracture
Acute on chronic heart failure
Acute hypoxia
Secondary diagnosis:
Aortic stenosis
Orthostatic hypotension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came in because you fell at your assisted ___
and broke a bone in your hip
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were seen by a cardiology team to check your heart
function
- You were given medication to remove excess fluid that
accumulated in your lungs and legs
- You had a procedure to remove excess fluid from beneath your
right lung
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Follow up with your primary care provider
- ___ yourself and contact your MD if you weight goes up by 3
lbs or more in 24 hours
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10412483-DS-19 | 10,412,483 | 24,877,573 | DS | 19 | 2133-07-08 00:00:00 | 2133-07-08 17:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ___
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with PMH of atrial
fibrillation on apixaban, moderate aortic stenosis ___ 1-1.5
cm2), HFpEF (EF 60% in ___, orthostatic hypotension on
midodrine, and prior falls who presents following an unwitnessed
fall in his bathroom.
Of note, the patient has had multiple falls in the past
complicated by several fractures. He previously was started on
midodrine and fludricortisone for presumed orthostatic
hypotension and did well on these medications, not falling for
over ___ year. Then, the patient was admitted to ___ in ___, after having a mechanical fall after developing
postural instability when standing up from his couch,
complicated
by pelvic fracture and intraperitoneal hematoma. He was seen by
cardiology for evaluation of recently diagnosed aortic stenosis
and it was felt that the patient's AS was not sufficiently
hemodynamically consequential to have caused the patient's fall.
The patient's midodrine/fludricortisone were held at discharge.
The patient's midodrine was restarted at some point and
uptitrated to a dose of 5mg TID.
The patient reports that the morning prior to presentation, he
was walking to the bathroom and became unsteady on his feet. He
denies preceding lightheadedness, chest pain, shortness of
breath, or palpitations. The patient fell against a wall,
slumped
to the floor, and was unable to get up. At no point during the
episode did the patient lose consciousness or suffer headstrike.
He activated his emergency help necklace and was brought to
___
ER for further evaluation.
In the ER, the patient's vitals were notable for T 97.2F, HR 88,
BP 147/79, RR 16, O2 sat 96% RA. Patient's labs were notable for
Hgb 10.9, MCV 102, INR 1.5, BUN 33, Cr 1.2, UA w/ 3 RBCs and no
bacteria. EKG demonstrated irregular rhythm, likely atrial
fibrillation, left bundle branch block, without any Sgarbossa
criteria met. CXR demonstrated increased vascular markings and
large right sided pleural effusion. Right hip XR was without
fracture. CT head and spine were without evidence of fracture.
The patient was given acetaminophen 1000mg x1 and admitted to
___ for further management.
Upon arrival to the floor, the patient confirmed the above
history.
REVIEW OF SYSTEMS:
A 10-point ROS was taken and is negative except otherwise stated
in the HPI.
Past Medical History:
Acute on chronic diastolic heart failure
Afib on Eliquis
Aortic Stenosis
Left Bundle Branch Block
Hypertension
Orthostatic hypotension
Early dementia/confusion
Depression
BPH
Social History:
___
Family History:
No family history of stroke. Father with CAD.
Physical Exam:
Admission Physical
==================
VITALS: T 97.4F, BP 181/99, HR 85, RR 18, O2 sat 94% RA
General: Alert, oriented to person, place, and circumstances of
hospitalization, no acute distress
HEENT: JVP measured approximately 6cm above the sternal angle
CV: ___ midsystolic murmur auscultated in bilateral second
intercostal spaces
Lungs: Decreased breath sounds in the lower right lung field
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: 1+ pretibial edema bilaterally
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength in bilateral upper and
lower
extremities. Sensation intact to light touch in all four
extremities. Normal finger-to-nose and heel-to-shin testing
bilaterally.
Discharge Physical
==================
General: Alert, lying comfortably in bed.
HEENT: No JVD.
CV: ___ midsystolic murmur auscultated in bilateral second
intercostal spaces. Irreg irregular.
Lungs: Decreased breath sounds RLL. Lungs clear in other areas.
Abdomen: Soft, non-tender, non-distended, no rebound or guarding
Ext: Trace edema in LLE. No edema in LLE.
Skin: Stasis dermatitis changes in LLE.
Neuro: CNII-XII intact, ___ strength in bilateral upper and
lower
extremities.
Pertinent Results:
Admission Labs
==============
___ 04:56PM BLOOD WBC-6.5 RBC-3.37* Hgb-10.9* Hct-34.2*
MCV-102* MCH-32.3* MCHC-31.9* RDW-13.0 RDWSD-48.6* Plt ___
___ 04:56PM BLOOD ___ PTT-32.8 ___
___ 04:56PM BLOOD Glucose-104* UreaN-33* Creat-1.2 Na-142
K-4.6 Cl-104 HCO3-26 AnGap-12
___ 08:10AM BLOOD Calcium-9.5 Phos-3.0 Mg-2.1
Discharge Labs
==============
___ 04:45AM BLOOD WBC-7.1 RBC-3.89* Hgb-12.6* Hct-39.4*
MCV-101* MCH-32.4* MCHC-32.0 RDW-13.2 RDWSD-48.9* Plt ___
___ 05:40AM BLOOD ___ PTT-33.8 ___
___ 04:45AM BLOOD Glucose-92 UreaN-27* Creat-1.1 Na-145
K-4.0 Cl-102 HCO3-30 AnGap-13
___ 04:45AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1
___ 07:44AM BLOOD VitB___-___ Folate-16
___ 04:56PM BLOOD TSH-2.3
Imaging & Studies
==================
CXR ___
Compared to chest radiographs since ___, most recently ___. Moderate chronic right pleural effusion slightly
smaller today than on ___. Substantial atelectasis right
lower lobe is chronic. Previous mild pulmonary edema has
resolved and mild cardiomegaly has improved. No pneumothorax.
TTE ___
Severe aortic valve stenosis. Mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global
biventricular systolic function. Mild-moderate pulmonary artery
systolic hypertension. Mild-moderate mitral regurgitation.
Possible secundum type atrial
septal defect.
Hip XR ___
No acute fracture. Chronic healed deformities of the right
superior and
inferior pubic rami.
CT head ___
No acute intracranial process.
CT c-spine ___
No fracture or malalignment. Partially visualized right pleural
effusion. Degenerative changes are similar to prior.
Microbiology
============
UCx ___
Contaminated
Brief Hospital Course:
Mr. ___ a ___ gentleman with PMH of atrial
fibrillation on apixaban, moderate aortic stenosis, HFpEF (EF
50% in ___, orthostatic hypotension on midodrine, and
prior falls who presents following a likely mechanical fall in
his bathroom. Patient was found to have had a heart failure
exacerbation, likely in the setting of underdiuresis and
worsening aortic valve disease. He was diuresed with Lasix
boluses and torsemide dose was increased to 20mg daily. He was
evaluated by cardiology who recommended dobutamine stress echo
as outpatient if patient expresses interest in TAVR (patient was
not interested at this time) to determine candidacy. He
continued to be orthostatic while euvolemic, so he has restarted
on midodrine with negative orthostatics.
# Acute on chronic HFpEF exacerbation:
Patient was diagnosed with HFpEF after developing lower
extremity edema in ___. TTE during that admission
demonstrated normal LV function, but severe RV systolic
dysfunction with estimated PASP of 44mmHg. It was recommended
that the patient could undergo cardiac MRI as an outpatient for
better evaluation of RV function. The cause of the patient's RV
dysfunction was unclear, and attributed to likely volume
overload and the patient's pleural effusion. TTE during this
admission demonstrated improved RV function, but worsening
aortic stenosis and increased filling pressures. Worsening
valvular disease may be responsible for heart failure
exacerbation. He was diuresed to euvolemia and torsemide was
increase to 20mg daily. He was restarted on midodrine prior to
discharge given positive orthostatics at euvolemia.
# Severe Aortic stenosis:
Patient was previously found to have moderate AS on TTE from
___. Now with severe by valve area, may be low-flow,
low-gradient. He was evaluated by cardiology who felt he may
have low-flow low-gradient AS that would be amenable to TAVR,
however patient did not want to undergo a procedure at this
time. Should he change his mind, he should undergo dobutamine
stress echo to determine candidacy for TAVR.
# Falls with concern for syncope
Patient presented after having fall at his assisted living
facility. Was using a walker at the time and notes no
lightheadedness, syncope, or presyncope. Worsening AS may be
responsible vs orthostasis which has been confirmed. TTE as
above and below. He will need close ___ follow-up and care to
avoid falling. No evidence of arrhythmias on telemetry.
# Pleural effusion:
Patient has chronic right-sided pleural effusion. Studies during
last admission c/w transudative effusion likely in setting of
heart failure. Improved slightly with diuresis. Consider
thoracentesis if develops worsening dyspnea.
# Atrial fibrillation:
Patient has chronic atrial fibrillation, with CHADSVASC 4. He
was continued on apixaban 2.5mg BID.
# Hyperlipidemia:
Continued home pravastatin
# Depression:
Continued home venlafaxine
Transitional Issues
===================
Discharge Weight: 60.9kg (134lbs)
[ ] Discharged on torsemide 20mg daily. Please weight patient
daily and call PCP or cardiologist if gains more than ___ lbs.
[ ] Please repeat Chem10 in ___ days to ensure that Cr is stable
[ ] Should follow up with cardiologist for further discussion
regarding TAVR. If patient decided to proceed with possible
intervention, would need dobutamine stress echo for further
evaluation.
[ ] Please monitor orthostatic vitals and adjust midodrine dose
as needed. After midodrine was restarted as inpatient, patient
was not orthostatic
[ ] Consider tapping R pleural effusion if develops symptomatic
dyspnea
#CODE: DNR/DNI
#CONTACT:
- ___ (son/HCP): ___
ATTENDING ATTESTATION:
I have seen and examined the patient, reviewed the findings,
data, and plan of care documented by the resident and agree,
except for the additional comments below.
Patient euvolemic appearing on day of DC with careful
instructions for contingencies for his new home health
assistant, including daily weights. Patient will have close
outpatient follow up for optimization of diuretic regimen and
consideration/further discussion re tavr, which was encouraged
by team upon DC.
___, MD
___ of Hospital ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Apixaban 2.5 mg PO BID
3. Venlafaxine XR 37.5 mg PO DAILY
4. Torsemide 10 mg PO DAILY
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. Midodrine 5 mg PO TID
7. Vitamin D 1000 UNIT PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 17.2 mg PO BID
10. Potassium Chloride 10 mEq PO DAILY
11. Pravastatin 80 mg PO QPM
12. Saccharomyces boulardii 250 mg oral DAILY
13. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
Discharge Medications:
1. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H
3. Apixaban 2.5 mg PO BID
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. Midodrine 5 mg PO TID
6. Polyethylene Glycol 17 g PO DAILY
7. Potassium Chloride 10 mEq PO DAILY
8. Pravastatin 80 mg PO QPM
9. Saccharomyces boulardii 250 mg oral DAILY
10. Senna 17.2 mg PO BID
11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
12. Venlafaxine XR 37.5 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14.Outpatient Lab Work
ICD10 I50.33 Acute on chronic diastolic heart failure
Please draw a Chem10 and fax results to:
___ c/o Dr. ___
___ c/o Dr. ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Aortic valve stenosis
Acute on chronic heart failure exacerbation
Secondary Diagnosis
===================
Orthostatic hypotension
Syncope
Mechanical fall
Pleural effusion
Hyperlipidemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had a fall, so you were admitted to the hospital for
further evaluation and to determine if you had worsening aortic
valve disease.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You underwent an echocardiogram (ultrasound of your heart)
that showed tightening of your aortic valve. We thought that
this could be contributing to your heart failure symptoms and
shortness of breath, so we asked cardiology to see you. They
determined that your valve was tight and you might be a
candidate for a procedure called a TAVR, which is a minimally
invasive procedure to replace the valve
- You said that you were not interested in any procedures at
this time, so we held off on more testing. If you decided you
are interested in this procedure, you should coordinate a
dobutamine stress echo to quantify the extent of your valve
disease to determine if you are a candidate for this procedure.
- You were found to be retaining extra fluid so we gave you
intravenous diuretics and you responded well. We increased your
dose of torsemide.
- You were found to be orthostatic (blood pressure drops with
standing) so we restarted midodrine.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please monitor your weight daily and call your primary care
doctor or cardiology if you weight increases or decreases by
more than ___ lbs.
- Please take extra care when standing or sitting to make sure
that you do not fall.
- Discuss potential for further workup and valve replacement
with your cardiologist as it may improve your symptoms.
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10412795-DS-5 | 10,412,795 | 29,235,206 | DS | 5 | 2134-04-30 00:00:00 | 2134-04-30 19:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, BRBRP, Afib
Major Surgical or Invasive Procedure:
Sigmoidoscopy ___
History of Present Illness:
___ year old male with history of
chronic back pain who was transferred from ___
where he initially presented from his PCP's office for ongoing
workup of abdominal pain and was found to be in afib and thus
referred to the ED.
The patient states that he first noticed mild abdominal pain in
___ and it has progressively become worse. The pain is mostly
located in the suprapubic and left lower quadrant. The pain is
constant and crampy and somewhat relieved with having a bowel
movement but never completely goes away. He develops significant
abdominal pain and distress after eating and within 15 minutes
has diarrhea. He has approximately ___ more episodes of diarrhea
over the next hour after eating. He is having around 8 bowel
movements a day and is also waking up at night with diarrhea. He
has significant urgency as well. He has tried cutting out coffee
and diary without any change in his symptoms. He has also
intermittently noticed blood in his stool, usually only a trace
of red blood, which he thinks is related to a hemorrhoid.
He has also has had a 30 lb weight loss during this time. He was
206lbs earlier in the ___ and 197lbs this morning on his
scale
at home. He saw his PCP several times for work-up during the
___ without any explanation for his symptoms.
He was taking extra strength Tylenol but was told his doctor to
discontinue this. He did have pneumonia in ___ and was
treated with steroids and antibiotics by his PCP.
He denies chest pain, dyspnea, fevers/chills, nausea, vomiting,
dysuria, and focal weakness. He denies night sweats but did have
one episode of sweating while at his PCP's office. Denies
palpitations. Endorses significant decline in his energy.
He denies any recent travel outside of ___. He did
travel to ___ but this was in his ___.
___ years ago he went to ___. Over the last ___ years he has
traveled only within ___.
In the ED, initial VS were: 99.1F, HR 79, BP 123/76, RR 18, 98%
on RA
Exam notable for: Irregular rhythm, occasional S3, abdomen soft,
non-tender, no HSM, no rebound. Rectal performed with chaperone
at bedside; frank blood, guaiac positive.
ECG: AF at rate of 116
Labs showed: WBC 13.1, Hb 13.7, Platelets 404, normal LFTs,
normal BMP, troponin negative x1, lactate 1.4, UA with 10
ketones, 3 RBC, 1 WBC
Imaging showed:
CT abdomen and pelvis:
1. Multifocal areas of colonic wall thickening and enhancement
with mild adjacent stranding, most notably in the distal
sigmoid,
proximal rectum, and hepatic flexure. Differential etiologies
include infectious, malignancy, inflammatory or ischemia. No
large vessel occlusion is demonstrated. There is diffuse
prominence of the mesenteric lymph nodes, which may represent
reactive
lymphadenopathy.
2. Multiple bilateral soft tissue pulmonary nodules, some with
surrounding ground-glass opacification, measuring up to 2.0 cm
right lower lobe which are suspicious for malignancy.
3. Redundant appearance of the distal esophagus/proximal stomach
appears consistent with a prior gastric fundoplication.
Recommend
correlation with patient's surgical history.
4. Sludge containing gallbladder without gallbladder wall
thickening or pericholecystic fluid.
5. Left adrenal nodule measuring 2.9 cm. Recommend nonurgent
adrenal CT, which may be performed as out patient.
Consults: GI felt unlikely to be a significant lower GI bleed
given Hb of 13.7 and recommended trending CBC and obtaining OSH
colonoscopy report. Cardiology recommended sending TSH, routine
TTE, holding A/C until bleeding stabilized, and starting DOAC as
soon as able.
Patient received: 1L NS and 12.5mg PO metoprolol tartrate
Transfer VS were: 98.9F, HR 115, 136/79, RR 21, 97% on RA
On arrival to the floor, patient recounts the above history. He
is not sure how much workup he wants to undergo as an inpatient
and if he needed a colonoscopy would want that to be done as an
outpatient.
Past Medical History:
Degenerative disc disease (L4-5)
Social History:
___
Family History:
Most of family history unknown. Father is living
and healthy. Step-brother had cancer by type unknown. No family
history of IBD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.9F, BP 119/81, HR 88, RR 18, 97%Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: irregular, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, discomfort with palpation in the
suprapubic and LLQ, otherwise nontender, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VITALS: T 98.1F, BP 115/66, HR 104, 97% on RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: irregular, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, discomfort with palpation in the
suprapubic and RLQ, otherwise nontender, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 04:30PM BLOOD WBC-13.1* RBC-4.46* Hgb-13.7 Hct-41.8
MCV-94 MCH-30.7 MCHC-32.8 RDW-12.1 RDWSD-41.9 Plt ___
___ 04:30PM BLOOD Neuts-42.8 Bands-0 ___ Monos-10.5
Eos-21.8* Baso-1 ___ Myelos-0 Im ___
AbsNeut-5.62 AbsLymp-3.08 AbsMono-1.38* AbsEos-2.87*
AbsBaso-0.13*
___ 04:30PM BLOOD ___ PTT-27.0 ___
___ 04:30PM BLOOD Glucose-82 UreaN-12 Creat-1.0 Na-140
K-5.1 Cl-102 HCO3-27 AnGap-11
___ 04:30PM BLOOD ALT-13 AST-19 AlkPhos-69 TotBili-0.7
___ 04:30PM BLOOD Lipase-36
___ 04:30PM BLOOD cTropnT-<0.01
___ 04:41PM BLOOD Lactate-1.4
PERTINENT LABS/MICRO/IMAGING:
=============================
___ 04:30PM BLOOD TSH-1.8
___ 06:38AM BLOOD Cortsol-19.6
SED RATE BY MODIFIED 36 H < OR = 20 mm/h
___
___ 16:30
STRONGYLOIDES ANTIBODY,IGG Results Pending
___ 8:23 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Preliminary):
OVA + PARASITES (Preliminary):
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
Cryptosporidium/Giardia (DFA) (Preliminary):
___ 2:00 pm STOOL CONSISTENCY: NOT APPLICABLE
C. difficile PCR (Pending):
Imaging:
--------
CT A/P w/ contrast ___:
1. Segmental thickening of the colon most notably at the sigmoid
colon and
proximal rectum. Differential etiologies include inflammatory
versus
infectious colitis. There is diffuse prominence of the
mesenteric lymph
nodes, which may represent reactive nodal enlargement.
2. Multiple bilateral pulmonary nodular opacities in the lower
lungs, may
reflect an infectious process. Recommend non-emergent Chest CT
to further
assess.
3. Moderate hiatal hernia.
4. Sludge containing gallbladder without gallbladder wall
thickening or
pericholecystic fluid.
5. Left adrenal nodule measuring 2.9 cm. Recommend nonemergent
adrenal CT,
which may be performed as out patient.
TTE ___:
Discrete upper septal left ventricular hypertrophy without LOVT
obstruction. Normal
biventricular global/regional systolic function. Biatrial
enlargement. Mild to moderate mitral regurgitation.
CT Chest w/o ___:
PRELIM:
1. Diffuse bilateral pulmonary nodules and masses including
solid and
ground-glass components range in size from 8 mm to 15 mm and are
concerning
for a neoplastic process. Recommend close attention on follow-up
CT chest
within 3 months.
2. Multiple scattered foci of ground-glass opacification in the
bilateral lung
bases is associated with enlarged mediastinal and hilar lymph
nodes which are
likely reactive.
3. Diffuse parenchymal abnormality including subpleural cystic
lesions and
reticular opacities may be seen in the setting of interstitial
lung disease,
such as NSIP.
4. Mildly dilated right pulmonary artery up to 3.1 cm.
DISCHARGE LABS:
===============
___ 08:15AM BLOOD WBC-11.6* RBC-4.31* Hgb-13.0* Hct-39.9*
MCV-93 MCH-30.2 MCHC-32.6 RDW-12.2 RDWSD-42.0 Plt ___
___ 05:15PM BLOOD ___
___ 08:15AM BLOOD Glucose-98 UreaN-8 Creat-1.1 Na-142 K-4.5
Cl-103 HCO3-26 AnGap-13
___ 08:15AM BLOOD TotProt-6.9 Calcium-8.7 Phos-3.6 Mg-1.9
___ 08:15AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 08:15AM BLOOD CRP-10.8*
Pending:
___ 08:15AM BLOOD PEP-PND
___ 02:04PM URINE U-PEP-PND
___ 08:15AM BLOOD tTG-IgA-PND antiDGP-PND
___ 08:23PM STOOL CALPROTECTIN, STOOL-PND
Brief Hospital Course:
___ year-old male with history of lower back pain who presents
with new onset atrial fibrillation and abdominal pain, diarrhea
and weight loss for 3 months, found to have findings concerning
for ulcerative colitis on sigmoidoscopy. Also with finding of
diffuse lung nodules concerning for neoplastic process and/or
interstitial lung disease.
ACUTE ISSUES:
==============
# Abdominal pain:
# Diarrhea:
# Weight loss:
# Concern for ulcerative colitis:
Patient presenting with 3 months of abdominal pain,
diarrhea(intermittently bloody), and weight loss with CT showing
multifocal areas of colonic wall thickening and enhancement with
mild adjacent stranding, most notably in the distal sigmoid,
proximal rectum, and hepatic flexure. Pathology from a
colonoscopy in ___ showed several tubular ademonas but also a
polyp with pathology showing crypt abscess formation. No
granulomas were seen. C diff and giardia testing were negative
in ___ at ___. Sigmoidoscopy this
admission showed diffuse colitis findings concerning for
ulcerative colitis. Biopsies obtained and pending. Started on
mesalamine ___ 4.8g PO daily and mesalamine 1g PR daily. Has
appointment with ___ GI in ___ and they will follow up
biopsy results.
# BRBPR:
Likely in the setting of colonic inflammation as above vs
hemorrhoids. Hemoglobin stable during hospitalization.
# Atrial fibrillation: CHA2DS2-VASc 1.
Patient presenting with new onset atrial fibrillation,
reportedly with RVR at the outside hospital. TTE showed biatrial
enlargement, mild to moderate mitral regurgitation, normal
biventricular global/regional systolic function. TSH within
normal limits. Started on metoprolol for rate control. Started
on Coumadin for anticoagulation given easier reversibility.
Discharged with ___. Plan for outpatient cardiology follow. INR
to be followed up by PCP, has appointment ___.
# Eosinophilia:
Patient with peripheral eosinophilia with absolute eos count
2,880. Labs from ___ at OSH also with eosinophilia. No signs of
end organ damage, LFTs normal. AM cortisol 19.6. Outpatient
follow up is recommended. Stronglyloides was sent and was
pending at the time of discharge.
#Pulmonary nodules.
Multiple pulmonary nodules noted on CT abdomen and pelvis which
were concerning for malignancy. CXR at ___ from ___ noted
"increased interstitial and mild increased alveolar opacities
are seen at both lung bases". CT chest showed diffuse bilateral
pulmonary nodules and masses including solid and ground-glass
components range in size from 8 mm to 15 mm and are concerning
for a neoplastic process. There was also concern for possible
underlying interstitial lung disease. Recommend close attention
on follow-up CT chest within 3 months.
Transitional issues:
====================
[ ] Sigmoidoscopy ___ showed diffuse colitis.
[ ] Please follow up GI biopsies.
[ ] Diagnosed with new atrial fibrillation. Started on
Metoprolol for rate control. Please monitor heart rate and
adjust accordingly.
[ ] Started on Warfarin for anticoagulation which will be
managed by his PCP. Follow up scheduled for ___.
[ ] Please follow up eosinophilia. Strongyloidis Ab pending.
[ ] Patient should get TB Quantiferon Gold test, in the setting
of treatment of IBD with immunosuppressive agents.
[ ] CT chest showed diffuse bilateral pulmonary nodules and
masses including solid and ground-glass components range in size
from 8 mm to 15 mm and are concerning for a neoplastic process.
Recommend close attention on follow-up CT chest within 3 months.
[ ] CT chest also showed diffuse parenchymal abnormality
including subpleural cystic lesions and reticular opacities may
be seen in the setting of interstitial lung disease, such as
NSIP. Recommend follow up CT as above. Consider referral to
pulmonology.
[ ] Left adrenal nodule measuring 2.9 cm. Recommend nonurgent
adrenal CT, which may be performed as out patient.
CORE MEASURES:
===============
#CODE: Full (presumed)
#CONTACT: son ___ ___
___ on Admission:
None
Discharge Medications:
1. Mesalamine (Rectal) ___AILY
RX *mesalamine [Canasa] 1,000 mg 1 suppository(s) rectally daily
Disp #*30 Suppository Refills:*0
2. Mesalamine ___ 4800 mg PO DAILY
RX *mesalamine 1.2 gram 4 tablet(s) by mouth daily Disp #*120
Tablet Refills:*0
3. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg 5 tablet(s) by mouth daily Disp #*100 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Atrial fibrillation
-Abdominal pain
-Diarrhea
SECONDARY:
-Pulmonary nodules
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were found to have
an irregular heart rhythm (Atrial fibrillation) and were having
months of abdominal pain, diarrhea, and intermittent bleeding.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You got a CT scan of your abdomen which showed inflammation in
the colon.
-You had a flexible sigmoidoscopy which showed swelling and
inflammation concerning for something called Ulcerative Colitis.
You will be started on treatment and will follow up with the
Gastroenterology team at ___.
-You had an ultrasound of your heart which showed normal pumping
function of the heart.
-You were started on a medication to slow down your heart rate.
You were also started on a blood thinner to prevent stroke in
the setting of your irregular heart rhythm, as people with
Atrial Fibrillation are at increased risk of forming clots that
can cause stroke.
-You were hooked up to a holter monitor so that your heart rate
and rhythm can be recorded and sent to your cardiologist (Dr.
___. You have a follow-up appointment with him (see below) for
further management.
-You had a CT scan of the chest. This showed multiple nodules
and masses, and need to be further worked up. A copy of the
report will be provided to your primary care doctor to follow
this up.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Please take all medications as prescribed.
-Please attend all ___ clinic appointments, listed below.
-You were given a holter monitor to record your heart rate and
rhythm, and you will follow up with your cardiologist.
-You were started on a blood thinner (warfarin/Coumadin). Be
aware that this medication thins your blood and may cause you to
bleed more/more easily.
-It is very important, as we discussed, to follow-up with your
PCP ___ on ___ ___ so that your INR can be checked
and your warfarin adjusted as necessary.
-After that, if you would like to establish care here at ___,
you can call Healthcare Associates at ___.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
10412940-DS-10 | 10,412,940 | 24,739,301 | DS | 10 | 2139-07-01 00:00:00 | 2139-07-01 23:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
morphine / oxycodone
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: ___ drainage of intra-abdominal fluid collection,
placement of 8 ___ pigtail catheter
History of Present Illness:
This is a ___ year-old gentleman with history of GERD and
hypertension, more recently perforated gangrenous appendicitis
for which he underwent laparoscopic appendectomy at ___
___ (___), now presenting with fevers. Postoperative
course was complicated by development of a right lower quadrant
intra-abdominal fluid collection s/p CT-guided percutaneous
drainage. Drain remained in place for nearly a week, during
which time he remained in the hospital and received IV
antibiotics. The drain was removed on ___ without
complications. Prior to this, patient had undergone a CT scan
which had showed complete drainage of the RLQ abscess, however
two new large fluid
collections were noted adjacent to the gallbladder, and a third
large collection by the inferior aspect of the spleen. Patient
was discharged from the hospital shortly thereafter and
completed a course of oral antibiotics (levofloxacin and
metronidazole), which stopped less than 24 hours prior to
presentation. He had been doing well, afebrile, until earlier
yesterday, when he experienced fever once again. Concerned for
worsening of intra-abdominal fluid collections (initial abscess
presented similarly), patient presented to outside hospital for
evaluation. Imaging once again confirmed the presence of
multiple abscesses, reportedly all smaller than those seen on
his last scan. He was administered a dose of Zosyn and
transferred to our institution
for further evaluation and management. Patient denies nausea,
vomiting, or worsening abdominal pain. Admits to decreased
appetite.
Past Medical History:
Past medical history:
Gastroesophageal reflux disease, obstructive sleep apnea,
hypertension, hyperlipidemia, colon polyps, diverticulosis
Past surgical history:
Laparoscopic appendectomy (___) for perforated gangrenous
appendicitis complicated by intraabdominal fluid collection s/p
percutaneous drainage, nasal surgery, traumatic head injury at
age ___
Social History:
___
Family History:
colon cancer
Physical Exam:
On Admission:
Vital signs - 98.8 76 138/60 18 96% RA
Constitutional - Well appearing, in no acute distress
Cardiopulmonary - RRR, normal S1 and S2. No murmurs, rubs or
gallops. Lungs are clear to auscultation bilaterally
Abdominal - Well healed incision scars from recent surgery.
Soft,
mildly distended, mild diffuse tenderness, worst at left upper
quadrant. No rebound or guarding
Extremities - Atraumatic. Warm and well-perfused
Neurologic - Alert and oriented x3. Grossly intact
On Discharge:
VS: 99/98.6 73 138/78 20 96%RA
Gen: NAD
Chest: RRR, no m/r/g, CTAB, nonlabored repirations
Abd: Soft, nondistended. Well healed incisions from surgery in
___. Nontender, no rebound or rigidity. Drain in place,
minimal output
extrem: no edema
Pertinent Results:
___ 06:36AM BLOOD WBC-11.9* RBC-3.92* Hgb-11.3* Hct-34.6*
MCV-88 MCH-28.9 MCHC-32.8 RDW-14.1 Plt ___
___ 01:07AM BLOOD WBC-14.5* RBC-4.27* Hgb-12.5* Hct-37.9*
MCV-89 MCH-29.2 MCHC-32.8 RDW-14.2 Plt ___
___ 01:07AM BLOOD Neuts-88.4* Lymphs-5.3* Monos-5.4 Eos-0.7
Baso-0.2
___ 06:36AM BLOOD Plt ___
___ 06:36AM BLOOD ___
___ 12:28PM BLOOD ___ PTT-29.5 ___
___ 01:07AM BLOOD Plt ___
___ 06:36AM BLOOD Glucose-129* UreaN-11 Creat-0.8 Na-136
K-3.7 Cl-104 HCO3-26 AnGap-10
___ 01:07AM BLOOD Glucose-97 UreaN-12 Creat-0.9 Na-139
K-4.5 Cl-104 HCO3-24 AnGap-16
___ 01:07AM BLOOD Glucose-97 UreaN-12 Creat-0.9 Na-139
K-4.5 Cl-104 HCO3-24 AnGap-16
___ 01:07AM BLOOD ALT-16 AST-16 AlkPhos-66 TotBili-0.4
___ 01:07AM BLOOD Lipase-29
___ 06:36AM BLOOD Calcium-7.6* Phos-3.1 Mg-1.8
___ 01:11AM BLOOD Lactate-1.3
___ 01:11AM BLOOD Lactate-1.3
___: ___ drainage:
Successful US-guided placement of ___ pigtail catheter into
the
collection. Sample was sent for microbiology evaluation.
Brief Hospital Course:
The patient presented to Emergency Department on ___ for
evaluation and management of abdominal pain. On CT
abdomen/pelvis, there was an intraabdominal fluid collection
found. Given findings, the patient was made NPO, given IVF. He
was admitted to the Acute Care surgery Service and
Interventional radiology was consultant for management of the
fluid collection and for possible drainage.
On ___, Type and screen sent and INR returned elevated at
1.7. ___ recommended to have INR 1.5 or less to do a drain.
Therefore the patient was scheduled to have a drain placed the
next day after FFP administered.
On ___, FFP was given at 4am, labs drawn at 6am and indicated
INR of 1.5. The patient subsequently had fluid collection
drained and an ___ pigtail catheter placed. Cultures were
sent to Microbiology from the abdominal fluid collection.
There were no adverse events in the ___ suite; please see the ___
procedure note for details.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was well controlled
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO after midnight
morning of procedure. Diet was advanced sequentially to a
Regular diet, which was well tolerated. Patient's intake and
output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. ___ drain left in place upon
discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge on ___, the patient was doing well,
afebrile and hemodynamically stable. The patient was tolerating
a diet, ambulating, voiding without assistance, and pain was
well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Finasteride 1 mg daily, ASA 81 mg daily, niacin 5 mg BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain Duration: 24 Hours
RX *acetaminophen 650 mg 1 tablet(s) by mouth q8hrs Disp #*40
Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 1 tablet(s) by mouth DAILY Disp #*40 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*40 Capsule Refills:*0
4. Pantoprazole 40 mg PO Q24H
5. Ibuprofen 600 mg PO Q8H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
6. Finasteride 1 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 7 Days
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tab by mouth
q8hrs Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
intra-abdominal fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for evaluation and management of your
abdominal pain. You were found to have an intrabdominal fluid
collection and had it drained by the interventional radiologists
during your hospitalization. You have recovered well and you are
now stable and ready for discharge.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10413130-DS-14 | 10,413,130 | 26,682,259 | DS | 14 | 2157-06-08 00:00:00 | 2157-06-09 11:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Edecrin / lisinopril / Lasix / Zyrtec / Avelox / Zyvox /
Metolazone / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Fatigue and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a PMH of HFpEF, bioprosthetic AVR,
CAD s/p 3V CABG ___, DVT, rectal cancer s/p colostomy, breast
cancer, who p/w fatigue and SOB.
History from patient and chart. Patient reports she has had
increasing SOB over the past few weeks. Today it was worse than
usual. Per chart, a friend noticed that she was wheezing and
found the nurse at her nursing care facility, and patient was
transported via EMS to ___. Patient felt symptomatic relief after
nebulizer en route.
Patient reports dry cough. No orthopnea or PND. She does note
baseline ___ edema, which has been unchanged. Denies recent fever
(she is uncertain, maybe had a fever "a while ago" at
facility?), chills, dysuria, abdominal pain, N/V. She lives in
assisted living at ___, where she does manage and take her
own medications. She is a former ___. She reports occasional
medication noncompliance, will sometimes forget to take
medications, but make it up later. She does note in particular
that she has a 2PM afternoon pill that she more frequently
forgets; she is on a home diuretic regimen of bumex 1 BID.
Of note, pt was discharged on ___ from ___ for CHF
exacerbation and bronchitis.
In the ED, initial VS were: 100.3 70 164/45 26 99% Nasal
Cannula. Temperature normalized without intervention, no other
s/s of infection. In the ED, she became hypertensive to SBPs
190s, and had increased respiratory distress, thought due to
flash pulmonary edema. She was briefly placed on BiPAP with
improvement of symptoms. She received 2 bumex IV in the ED, SL
nitro x2, as well as her home carvedilol and hydralazine, which
she had apparently missed earlier in the day, with improvement
of symptoms.
On arrival to the CCU, patient is feeling well. Denies SOB or
CP. Appearing comfortable on 4L O2 NC.
Transfer VS were: 98.4, P82, 160/43, RR15, 96% 4L NC
Past Medical History:
- Hyponatremia/? SIADH
- HFpEF
- CAD s/p CABG ___
- Aortic stenosis s/p AVR with bioprosthetic valve ___
- HTN
- Hypercholesterolemia
- GERD
- Breast cancer s/p lumpectomy, adjuvant chemotherapy,
anastrozole
- Atrial ectopy (previously on digoxin)
- Osteopenia
- Macular Degeneration
- Rectal cancer s/p neoadjuvant radiation and surgery ___. W/
colostomy
- LUL Lung nodule s/p cyberknife
Social History:
___
Family History:
None pertinent to this admission.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T: 98.0 HR: 74 BP: 168/46 O2: 95% on 4L NC RR: 24
GENERAL: Pt sitting comfortably in bed, speaking in complete
sentences and in no acute distress.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVD 13 at 45 degrees
HEART: RRR, S1/S2, ___ systolic crescendo decrescendo murmur
with high pitched diastolic murmur
LUNGS: comfortable on O2 NC, no accessory muscle use, scattered
wheeze, crackles bilateral from bases to mid lung.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, colostomy bag present
EXTREMITIES: no cyanosis, clubbing. 1+ ___ edema symmetric
bilaterally to mid shin.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8 125/51 69 18 95 RA
GENERAL: Pt sitting comfortably in bed, speaking in complete
sentences and in no acute distress.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVD 12 at 45 degrees
HEART: RRR, S1/S2, ___ systolic crescendo decrescendo murmur
with high pitched diastolic murmur
LUNGS: comfortable on O2 NC, no accessory muscle use, scattered
wheeze, crackles bilateral from bases to mid lung.
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, colostomy bag present
EXTREMITIES: no cyanosis, clubbing. trace edema in extremities
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
============================
___ 08:35PM BLOOD WBC-10.0 RBC-3.79* Hgb-11.4 Hct-36.2
MCV-96 MCH-30.1 MCHC-31.5* RDW-16.6* RDWSD-58.4* Plt ___
___ 08:35PM BLOOD Neuts-85.0* Lymphs-6.2* Monos-7.1 Eos-1.0
Baso-0.3 Im ___ AbsNeut-8.45* AbsLymp-0.62* AbsMono-0.71
AbsEos-0.10 AbsBaso-0.03
___ 08:35PM BLOOD ___ PTT-27.9 ___
___ 08:35PM BLOOD Glucose-117* UreaN-32* Creat-0.9 Na-142
K-4.9 Cl-103 HCO3-24 AnGap-15
___ 08:35PM BLOOD proBNP-3755*
___ 08:35PM BLOOD cTropnT-0.08*
___ 10:43AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1
PERTINENT LABS:
=============================
Electrolytes and creatinine trend:
___ 01:13AM BLOOD Glucose-119* UreaN-32* Creat-0.8 Na-143
K-3.5 Cl-101 HCO3-24 AnGap-18*
___ 05:24AM BLOOD Glucose-110* UreaN-35* Creat-0.9 Na-139
K-4.7 Cl-101 HCO3-24 AnGap-14
___ 04:35AM BLOOD Glucose-98 UreaN-34* Creat-0.9 Na-140
K-4.4 Cl-101 HCO3-25 AnGap-14
DISCHARGE LABS:
=============================
___ 06:20AM BLOOD WBC-4.7 RBC-3.18* Hgb-9.5* Hct-30.2*
MCV-95 MCH-29.9 MCHC-31.5* RDW-16.1* RDWSD-56.4* Plt ___
___ 06:20AM BLOOD Glucose-105* UreaN-37* Creat-0.9 Na-143
K-3.9 Cl-101 HCO3-26 AnGap-16
___ 06:20AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.8
STUDIES:
=============================
___ CXR:
Stable cardiac and mediastinal silhouettes. Increased
interstitial markings bilaterally suggest mild to moderate
interstitial edema, however underlying infection is not excluded
in the appropriate clinical setting.
___ CXR:
Increased bilateral ground-glass opacities, most concerning for
moderate
pulmonary edema though difficult to exclude superimposed
infection.
___ CXR:
In comparison with the study of ___, there again is
enlargement of the cardiac silhouette in a patient with intact
midline sternal wires. Bilateral opacifications are consistent
with pulmonary edema, though in the appropriate clinical setting
would be difficult to exclude superimposed aspiration/pneumonia.
Mass in the left hilar and suprahilar region is consistent with
malignancy and there is an associated fiducial marker.
Retrocardiac opacification is consistent with volume loss in the
left lower lobe and there are small bilateral pleural effusions.
___ Renal US: To evaluate for renal artery stenosis
Suboptimal renal doppler study showing appropriate flow in the
left kidney but the flow in the right kidney could not be
properly assessed. Limited views demonstrate cortical atrophy
of the right kidney. Could consider CT or MR study for more
optimal evaluation for renal artery stenosis.
___ TTE
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. A bioprosthetic
aortic valve prosthesis is present. The prosthetic aortic valve
leaflets are thickened. The transaortic gradient is higher than
expected for this type of prosthesis. Mild to moderate (___)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate (___) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Brief Hospital Course:
___ with a h/o of HFpEF (LVEF>55%), AS s/p bioprosthetic AVR
(___), CAD s/p 3V CABG (___), DVT, rectal cancer s/p
colostomy, breast cancer, who presented with dyspnea, found to
be in decompensated heart failure.
# CORONARIES: s/p 3v CABG (___)
# PUMP: LVEF>55%
# RHYTHM: normal sinus, LBBB
=============
ACUTE ISSUES:
=============
# Heart Failure with Preserved EF
Patient presented with fatigue and shortness of breath. She was
found to be in decompensated heart failure, with elevated BNP
>3000 and a CXR showing diffuse pulmonary edema. Patient does
note occasional medication noncompliance at home, which is the
most likely cause of her exacerbation. She was diuresed with IV
bumex this admission. She was continued on her home losartan,
amlodipine, and carvedilol. Her home hydralazine was increased
from 50 to 100 TID. She was discharged on an outpatient diuretic
regimen of PO bumex 2 BID.
# Flash pulmonary edema
Patient did have an episode of respiratory distress thought to
be flash pulmonary edema in the ED, in the setting of
uncontrolled hypertension with SBP in the 190s. She was placed
briefly on BiPAP with improvement of her symptoms. She received
nitro SL, as well as her home antihypertensives, to good effect.
# HTN
She had an episode of significantly elevated BPs in the ED, with
SBPs in 190s. She was resumed on her home antihypertensives
losartan, amlodipine and carvedilol; her home hydralazine was
increased from 50 to 100 TID, for persistent hypertension with
SBPs in 150s. She did receive a renal Doppler to evaluate for
renal artery stenosis, which was unrevealing.
# Deconditioning: ___ evaluated patient and recommended discharge
to rehab.
===============
CHRONIC ISSUES:
===============
# CAD: Continued aspirin 81, simvastatin 20, carvedilol 25 BID
# Hyponatremia: Thought due to mild SIADH and excess fluid
intake. Followed by nephrology as an outpatient
# GERD: Continued omeprazole 40
# Anemia: Continued ferrous sulfate
# Breast Cancer. ER/PR+, Her2 neg, s/p lumpectomy, on
anastrazole: Continued home Anastrozole 1 mg QD
# Hypothyroidism: Continued levothyroxine 50 mcg QD
# CODE: FULL
# CONTACT/HCP: ___ (cousin): ___
===============
CHRONIC ISSUES:
===============
# CAD: Continued aspirin 81, simvastatin 20, carvedilol 25 BID
# Hyponatremia: Thought due to mild SIADH and excess fluid
intake. Followed by nephrology as an outpatient
# GERD: Continued omeprazole 40
# Anemia: Continued ferrous sulfate
# Breast Cancer. ER/PR+, Her2 neg, s/p lumpectomy, on
anastrazole: Continued home Anastrozole 1 mg QD
# Hypothyroidism: Continued levothyroxine 50 mcg QD
# CODE: FULL
# CONTACT/HCP: ___ (cousin): ___
TRANSITIONAL ISSUES:
- Please closely monitor volume status
- Patient was discharged on outpatient diuretic regimen of PO
bumex 2 BID.
- Discharge weight: 71.8kg (158.29 lbs)
- Please follow up on blood pressure control
- Her home hydralazine was increased from 50 to 100 TID, please
continue to monitor blood pressure
- Patient discharged with mild anemia H&H 9.5* 30.2* from a
normal baseline. Please repeat CBC in one week to ensure
resolution.
NEW/CHANGED MEDICATIONS:
- bumex increased to 2 BID (from 1 BID)
- hydralazine increased to 100 TID (from 50 TID)
STOPPED MEDICATIONS:
- none
# CODE: FULL
# CONTACT/HCP: ___ (cousin): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Anastrozole 1 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Senna 8.6 mg PO BID
6. amLODIPine 5 mg PO DAILY
7. HydrALAZINE 50 mg PO TID
8. L.acidoph,saliva-B.bif-S.therm 175 mg oral DAILY
9. Simvastatin 20 mg PO QPM
10. Ferrous Sulfate 325 mg PO DAILY
11. Bumetanide 1 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 600 mg
calcium (1,500 mg)-800 unit tablet,chewable oral BID
15. Aspirin 81 mg PO DAILY
16. Levothyroxine Sodium 50 mcg PO DAILY
17. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Bumetanide 2 mg PO BID
2. HydrALAZINE 100 mg PO TID
3. amLODIPine 5 mg PO DAILY
4. Anastrozole 1 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 600 mg
calcium (1,500 mg)-800 unit tablet,chewable oral BID
7. Carvedilol 25 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. L.acidoph,saliva-B.bif-S.therm 175 mg oral DAILY
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Losartan Potassium 100 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 40 mg PO DAILY
15. Senna 8.6 mg PO BID
16. Simvastatin 20 mg PO QPM
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute decompensted heart failure with preserved ejection
fraction
SECONDARY DIAGNOSIS:
Flash pulmonary edema
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WERE YOU ADMITTED?
- You were admitted because of your shortness of breath
- You were found to be in a heart failure exacerbation
WHAT HAPPENED IN THE HOSPITAL?
- You received breathing support initially with oxygen and with
a special breathing mask
- You received medicines to help you eliminate the extra fluid
built up in your lungs from your heart failure
- You received medicines to treat your high blood pressure,
which was contributing to your shortness of breath
WHAT SHOULD YOU DO AT HOME?
- Please take all your medicines as prescribed
- Please go to all your follow up appointments as scheduled
- If you gain more than 3 pounds in 3 days, please call your
doctor
___ was a pleasure taking care of you, we wish you the best!
Your ___ Team
Followup Instructions:
___
|
10413783-DS-10 | 10,413,783 | 29,078,905 | DS | 10 | 2192-06-28 00:00:00 | 2192-06-28 19:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Amiodarone
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient ___ ___ is a ___ M w/ PMH afib on
___, alcohol use (unclear if active), T2DM, presumptive
seizure disorder followed by Dr. ___.
history per chart review and OSh records. Attempted to reach his
wife at number listed in OMR for collateral, but there was no
answer.
Patient was found on the floor at ___ (where he works)
with reported GTC, the duration of which is unclear. He received
5 mg valium per EMS. He was then brought to ___. At ___,
he received 1mg Ativan and 1000 mg keppra on arrival, it is not
exactly clear why. His BP was 226/145 initially. He later became
hypotensive with propofol. He had NCHCT done with no acute
process, it did redemonstrate an area of L parietal
encephalomalacia. CT C spine showd cervical spondlyosis. He
received clindamycin 900 mg for unclear reasons. He was
intubated
as he was felt to not be protecting his airway. He had presented
there around initially 1200. They discussed with neurology
there,
who recommended transferring the patient to a higher level of
care due to the possible need for cvEEG. No further information
is able to be obtained. There was report that CT C spine showed
evidence of aspiration, which was thought to have occurred prior
to intubation.
Labs were as follows
WBC 7.8, hgb 14.5 plts 186
Chem7 137 K 4.8, Cl 100, Co2 27 BUN 21, Cr 0.8, Glu 119
INR 1.3
Ca 9.4
AST 32 ALT 26 Trop 0.01 Alb 4.1 tprotein 7.5
UA 1 WBC
Utox: benzo+, cannabinoid+
no serum ethanol level checked.
No lactate.
In reviewing his chart, he is followed for presumptive seizures
by Dr. ___ sees him at ___. He was most recently
seen in ___ this year. In reviewing his records it does not
seem he has ever had a GTC before.
His typical seizure semiology is described as numbness/tinling
in
R hand than can lead to hand tightening, followed by inability
to
speak +/- garbled speech with confusion, LOC, there have been
prolonged periods of expressive aphasia. There can be aura. At
his last visit, he had not had any of these from ___ to
___. In his ___ Visit he had reported 4 seizures over the
previous 6 months, but he did also endorse some memory issues.
In
the notes, the wife reports >25 seizures over a ___ year period at
one point in the past, where he had only recalled around ___.
He has issues with medication adherence. He forgots to take his
medications at times. His levels have been not therapeutic at
times. Outpatient keppr alevels have included most recently 52,
prior 49 and <2. His lamictal levels have included 7.2, 7.6,
1.2.
Has filled rx's inconsistently.
He is currently maintained on keppra ER 1500 mg BID, lamictal ER
200 mg BID
He tried zonisamide in the past but did not tolerate due to
cognitive side effects.
His seizures began around ___. He had a L temporoparietal area
meningioma discovered a few weeks later after the first event,
the meningioma was then resected. He was initially on phenytoin.
At some points it seems that his seizures have started several
days after he stops drinking. He has still had them during times
of alcohol abstinence. At his last clinic visit in ___ he
had reported that he had not been drinking. In an admission in
___, it was noted that he had been drinking ___ pint liquor per
day.
EEG has shown L anterior quadrant discharges in the past.
Ambulatory EEG in ___ did show L temporal epileptiform
discharges, bursts of focal slowing in the L posterior quadrant.
Unable to obtain ROS.
Past Medical History:
- Left parietal meningioma s/p resection (___) c/b complex
partial seizures (seen by ___ prior, first seizure in
___
- Alcohol abuse
- Hypertension
- CAD s/p Promus stent x 2 to proximal/mid LAD ___
- Moderate chronic congestive heart failure
- Atrial fibrillation
- Atrial flutter ablation
- Type 2 Diabetes
- Dyslipidemia
- Obesity
Social History:
___
Family History:
Patient was adopted and does not know family history.
Physical Exam:
EXAM ON ADMISSION:
=================
Vitals: T97.9 HR 88 122/75 24 100%
General: intubated, sedated
HEENT: no scleral icterus MMM, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. in c collar
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
Propofol, fentanyl paused for 5 min prior to exam
-Mental Status:
moving arms and legs spontaneously. Does not open eyes to voice,
sternal rub. Does not follow commands.
-Cranial Nerves:
Corneals+. Pupils 2->1 b/l. VOR deferred, c collar. + Cough.
-Motor/sensory: moves all extremities spontaneously in plane of
bed. withdraws to noxious in all.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
EXAM ON TRANSFER FROM ICU ___:
Tmax: 37.1 °C (98.7 °F)
T current: 37.1 °C (98.7 °F)
HR: 83 (78 - 93) bpm
BP: 102/59(73) {82/55(67) - 139/97(106)} mmHg
RR: 19 (15 - 24) insp/min
SPO2: 96%
Heart rhythm: AF (Atrial Fibrillation)
Height: 69 Inch
Fluid balance24 hoursSince 12 a.m.
Total In:102 mL576 mL
PO:
Tube feeding:
IV Fluid:102 mL576 mL
Blood products:
OR Intake:
Total out:30 mL315 mL
Urine:30 mL315 mL
NG:
Stool:
Drains:
CT Drain:
OR Output:
Balance:72 mL261 mL
General: awake, alert, interactive
HEENT: bruise over the right eye
Neck: in c-collar
CV: tachycardic
Lungs: clear to auscultation
Abdomen: soft
GU: foley in place
Ext: bump over knee, chronic per patient
Skin: bruising over right eye
Neuro:
MS- interactive, following commands, able to state name, month,
year and that he had a seizure today
CN- Pupils 3-> 2mm, face symmetric, tongue midline
Sensory/Motor- moves all extremities spontaneously and with full
strength
Coordination- not assessed
Discharge Physical Exam:
VS
24 HR Data (last updated ___ @ 551)
Temp: 99.0 (Tm 99.6), BP: 131/73 (131-173/73-93), HR: 78
(73-101), RR: 16 (___), O2 sat: 94% (94-99), O2 delivery: Ra
General: awake, alert, interactive
HEENT: bruise over the right eye
CV: warm, well-perfused
Lungs: clear to auscultation
Abdomen: soft
Ext: bump over knee, chronic per patient
Skin: bruising over right eye
Neuro:
- Mental status: Awake, alert, oriented to self, ___, date.
Able to relate history without difficulty. Attentive to name
months of the year backwards without difficulty. Speech is
fluent with full sentences, intact repetition, and intact verbal
comprehension. Naming intact. No paraphasias. No dysarthria.
Normal prosody. No evidence of hemineglect. No left-right
confusion. Able to follow both midline and appendicular
commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric. Trapezius
strength ___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. No drift. No tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [FEx] [IP] [Quad] [Ham] [TA] [Gas]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
- Sensory: No deficits to light touch b/l.
- Reflexes: deferred
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed on fingertapping b/l
- Gait: deferred
Pertinent Results:
___ 07:56PM BLOOD WBC-13.8* RBC-5.09 Hgb-15.5 Hct-47.3
MCV-93 MCH-30.5 MCHC-32.8 RDW-13.0 RDWSD-44.1 Plt ___
___ 01:50AM BLOOD WBC-20.3* RBC-4.65 Hgb-13.4* Hct-44.4
MCV-96 MCH-28.8 MCHC-30.2* RDW-13.2 RDWSD-46.2 Plt ___
___ 06:40AM BLOOD WBC-8.2 RBC-4.10* Hgb-12.0* Hct-36.7*
MCV-90 MCH-29.3 MCHC-32.7 RDW-13.0 RDWSD-42.4 Plt ___
___ 07:56PM BLOOD Neuts-87.4* Lymphs-6.6* Monos-4.1*
Eos-1.1 Baso-0.4 Im ___ AbsNeut-12.08* AbsLymp-0.91*
AbsMono-0.57 AbsEos-0.15 AbsBaso-0.05
___ 10:00PM BLOOD Neuts-84.5* Lymphs-7.7* Monos-5.0 Eos-1.9
Baso-0.3 Im ___ AbsNeut-13.07* AbsLymp-1.19* AbsMono-0.77
AbsEos-0.29 AbsBaso-0.05
___ 06:40AM BLOOD ___ PTT-33.1 ___
___ 06:40AM BLOOD Glucose-100 UreaN-12 Creat-0.6 Na-141
K-4.3 Cl-102 HCO3-26 AnGap-13
___ 01:50AM BLOOD ALT-22 AST-39 LD(LDH)-446* CK(CPK)-175
AlkPhos-51 TotBili-0.6
___ 07:56PM BLOOD Lipase-40
___ 07:56PM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.6
___ 10:00PM BLOOD Calcium-8.6 Phos-1.8* Mg-1.7
___ 07:56PM BLOOD ASA-NEG Ethanol-10 Acetmnp-NEG
Tricycl-NEG
___ 08:07PM BLOOD Lactate-1.5
CT Head wo cont ___:
IMPRESSION:
1. No acute intracranial hemorrhage or evidence of acute
territorial
infarction.
2. A 1.5 cm extra-axial partially calcified mass superior to the
left petrous ridge likely represents a meningioma.
3. Postsurgical changes from left parietal craniotomy. Left
parieto-occipital encephalomalacia.
CXR AP ___:
IMPRESSION:
Comparison to ___. The patient has been extubated.
The feeding tube was removed. As expected, lung volumes have
decreased, with an increase in extent and severity of the
pre-existing right basal parenchymal opacity.
Also increased is the size of the cardiac silhouette. The pre
described signs of pulmonary edema are visually less obvious
than on the previous examination.
No pleural effusions. No pneumothorax.
MRI brain w wo cont ___ IMPRESSION:
1. Study is moderately degraded by motion.
2. Grossly stable postsurgical changes related to patient's
known left
parietal craniotomy and left petrous ridge meningioma resection.
3. Grossly stable approximately 1.4 cm left petrous ridge
probable meningiomaas described, grossly unchanged compared to
___ prior exam.
4. No acute intracranial abnormality, with no definite evidence
of acute infarct.
5. Paranasal sinus disease, as described.
Brief Hospital Course:
Mr. ___ is a ___ year old man atrial fibrillation on
___, DM2, epilepsy, prior left temporoparietal meningioma
s/p resection who presented with breakthrough seizures initially
requiring intubation and ICU admission, now extubated and
seizure-free. Neurological exam is reassuringly non-focal.
Differential for breakthrough seizures includes medication
non-adherence vs infectious etiology resulting in lower seizure
threshold. He required 1 bolus of IVF overnight ___ and was
brought back to the ICU, where he remained stable with no
further hemodynamic instability and ready for transfer out from
ICU to floor. He was hemodynamically stable on the floor and
symptoms improved.
Plan:
# Breakthrough seizures
DDx medication nonadherence, infection
- f/u keppra levels (sent as add-on to admission labs ___,
unclear if trough or random though)
- lamotrigine level low at 4.0
- continue keppra 1500mg BID (XR)
- lamotrigine ER increase to 200 mg qAM, 250 mg qPM for 1 week.
Then, will instruct patient to increase to 200 mg qAM, 300 mg
qPM.
#Community-acquired pneumonia
- d/c IV antibiotics after 1 day
- doxycycline 100 mg BID last day on ___
- cefpodoxime 400 mg BID last day on ___
#Meningioma
- CT and MRI scans show 1.4 cm left petrous ridge likely
meningioma
- will have outpatient neurosurgery follow-up
# afib, hyperlipidemia, hypertension
- continue ___ 150mg BID
- continue digoxin 125 ucg
- continue simvastatin 80
- continue furosemide
- continue nadolol 40mg BID
- continue tamsulosin 0.4 mg daily
#Anemia
- will need to repeat CBC as outpatient
#Hypophosphatemia
- improved with supplementation
=============================================
Transitional Issues:
[]repeat CBC and phosphorus in 1 week at PCP ___
[]f/u with PCP ___ ___ weeks
[]f/u with Epilepsy (Dr. ___ on ___
[]f/u with neurosurgery on ___ for meningioma
[] repeat lamotrigine level at next appointment
Medications on Admission:
per pharmacy ___ 150 mg BID
Lasix 20 mg daily
nadolol 40 mg BID
tamsuolosin 0.4 mg daily
folic acid 1 mg daily
Digoxin 125 mcg daily
simvastatin 80 mg daily
keppra ER 1500 mg BID
lamictal ER 200 mg BID
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO BID Duration: 5 Doses
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO BID
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*5 Tablet Refills:*0
3. LORazepam 1 mg PO BID:PRN aura/seizures
RX *lorazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*2
4. LaMICtal XR (lamoTRIgine) 250 mg oral QPM
RX *lamotrigine [Lamictal XR] 250 mg 1 tablet(s) by mouth once a
night Disp #*6 Tablet Refills:*0
5. LaMICtal XR (lamoTRIgine) 250 mg oral QPM Duration: 6 Doses
6. LaMICtal XR (lamoTRIgine) 300 mg oral QPM
RX *lamotrigine [Lamictal XR] 300 mg 1 tablet(s) by mouth once a
night Disp #*30 Tablet Refills:*5
7. Dabigatran Etexilate 150 mg PO BID
8. Digoxin 0.125 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Keppra XR (levETIRAcetam) 1500 mg oral BID
11. LaMICtal XR (lamoTRIgine) 200 mg oral QAM
12. Nadolol 20 mg PO BID
13. Simvastatin 40 mg PO QPM
14. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Breakthrough seizures
Secondary diagnoses:
Community-acquired pneumonia
Atrial fibrillation
Meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital due a breakthrough seizure.
This likely happened because of pneumonia and missing doses of
your seizure medications.
You were treated with antibiotics. Continue these through
___.
Doxycycline 100 mg twice a day
Cefpodoxime 400 mg twice a day
Continue Keppra XR 1500 mg twice a day
Lamictal XR increased to 200 mg in the morning and 250 mg at
night for 1 week.
On ___, increase to 200 mg in the morning and 300 mg at night.
Take the rest of your medications as prescribed.
Follow up with your PCP ___ ___ weeks. You need some repeat
blood tests to check for anemia and electrolyte levels.
Follow up with Dr. ___ as listed below.
You were found to have another meningioma. Follow up with
neurosurgery. An appointment was made for you below.
Thank you for the opportunity to participate in your care.
Sincerely,
Your ___ Neurology team
Followup Instructions:
___
|
10413783-DS-8 | 10,413,783 | 27,685,534 | DS | 8 | 2188-02-13 00:00:00 | 2188-02-13 17:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Amiodarone
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Reason for Consultation: Seizure
HPI: The patient is a ___ year old man with past medical history
significant for left parietal meningioma s/p resection (___)
c/b
complex partial seizures and alcohol abuse who was transferred
to
___ ___ ___ after having two seizures.
Pt was at work at ___ when he began to feel like he "was
going to have a seizure". He felt numb on his right side, which
typically happens prior to a seizure. He then lost awareness. A
co-worker found him confused and per OSH report his "eyes were
open but he was not following commands". An ambulance was
called.
En route to the ___, he was given 20 mg IV Cardizem for afib with
RVR with HR to the 140s. In the ___, he was noted to have
a right-sided facial droop, "aphasia" and right sided neglect
(typical for patient post-ictally per wife). In the ___,
he had a generalized tonic clonic seizure which was witnessed by
___ staff. He was given 6 mg IV ativan and 1500 IV Keppra and
transferred to ___ for further management.
At ___, he was placed on CIWA and given 10 PO diazepam. He was
also given 2 IV lorazepam and 30 PO diltiazem for HR 120s.
Otherwise, pt reports missing his home medications on day of
presentation. He last had a seizure ___ months ago. He had been
drinking about a half pint per day over the past week and
doesn't
report a clear precipitator for this drinking binge.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or
retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
PMH/PSH:
- Left parietal meningioma s/p resection (___) c/b complex
partial seizures (seen by ___ prior, first seizure in
___
- Alcohol abuse
- Hypertension
- CAD s/p Promus stent x 2 to proximal/mid LAD ___
- Moderate chronic congestive heart failure
- Atrial fibrillation
- Atrial flutter ablation
- Type 2 Diabetes
- Dyslipidemia
- Obesity
Social History:
___
Family History:
Patient was adopted and does not know family history.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 97.9 HR: 110 BP: 141/93 RR: 18 SaO2: 97% RA
General: NAD, disheveled
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: Irregularily irregular
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, oriented to person, place, and time;
however was only accurate after I repeated the questions several
times. Inattentive. Does not recall a coherent history. Able to
recite months of year backwards but is slow. Speech is fluent
with intact repetition and verbal comprehension. Content of
speech demonstrates intact naming (high and low frequency) and
no
paraphasias. Normal prosody. No dysarthria. No apraxia. No
evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 4->3. VF full to number counting. EOMI,
no nystagmus. V1-V3 without deficits to light touch bilaterally.
No facial movement asymmetry. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. Mild intention tremor
bilaterally.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Normal rapid alternating movements.
- Gait - Stable without sway. Negative Romberg.
#####DISCHARGE EXAM#####
Notable changes:
Mental Status: Alert, Oriented x3, conversant and fluent.
Provides clear history, but struggles with specifics (names of
his medications, who prescribes his medication). Felt to be at
mental status baseline. Otherwise as above.
Pertinent Results:
___ 06:17AM BLOOD WBC-12.1* RBC-4.59* Hgb-14.8 Hct-44.2
MCV-96 MCH-32.2* MCHC-33.5 RDW-13.6 Plt ___
___ 07:45PM BLOOD Neuts-78.7* Lymphs-15.4* Monos-4.5
Eos-1.0 Baso-0.4
___ 06:17AM BLOOD ___ PTT-39.1* ___
___ 06:17AM BLOOD Glucose-119* UreaN-12 Creat-0.7 Na-139
K-3.6 Cl-96 HCO3-30 AnGap-17
___ 06:17AM BLOOD ALT-27 AST-34 AlkPhos-86 TotBili-1.1
___ 06:17AM BLOOD cTropnT-<0.01
___ 07:45PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 06:17AM BLOOD LEVETIRACETAM (KEPPRA)-PND
Final EEG from ___ and ___ pending on discharge.
Brief Hospital Course:
# Seizure
- Patient was admitted to the general neurology service and
started on EEG. CBC was notable for elevated WBC (likely from
seizures), but u/a and CXR benign. He was continued on his home
Keppra. Final EEG read was pending, but no further seizure
activity was seen during this hospitalization. The etiology for
his seizures was assumed to be the combination of acute alcohol
withdrawal and missed doses of his Keppra. A keppra level was
sent, but pending at a time of discharge. He returned to his
baseline and was felt to be safe for outpatient management.
Mass. Law regarding seizures and operating a motor vehicle was
discussed with the patient. Patient was provided the number to
schedule his follow-up neurology appointment, as he requested it
not be scheduled for him.
# Alcohol Abuse and Possible Withdrawal: He was counseled on
alcohol cessation and alcohol's role in instigating seizures.
He did demonstrate some evidence of hepatic dysfunction
(elevated INR to 1.4, ___ of 14.6), though LFTs were normal.
However, Pradaxa may be playing a role in this mild elevation.
Recommend outpatient evaluation and counselling for alcohol
abuse. While in the hospital, CIWA scores were monitored.
Patient did receive a total of 10mg Diazepam this admission, but
primarily in the setting of agitation and constantly removing
EEG leads. Patient did not have objective evidence for
withdrawal, but this medication was given as irritability
related to acute cessation of alcohol could easily be feeding in
to his agitation concerning the EEG.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dabigatran Etexilate 150 mg PO BID
2. Dofetilide 250 mcg PO Q12H
3. Furosemide 20 mg PO DAILY
4. LeVETiracetam 1500 mg PO BID
5. Simvastatin 80 mg PO QPM
6. Nadolol 40 mg PO Q6H
7. Digoxin 0.25 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Magnesium Oxide 400 mg PO TID
10. Aspirin 325 mg PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO TID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Dabigatran Etexilate 150 mg PO BID
3. Digoxin 0.25 mg PO DAILY
4. Dofetilide 250 mcg PO Q12H
5. Fish Oil (Omega 3) 1000 mg PO TID
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. LeVETiracetam 1500 mg PO BID
9. Magnesium Oxide 400 mg PO TID
10. Magnesium Oxide 400 mg PO TID
11. Nadolol 40 mg PO Q6H
12. Simvastatin 80 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the hospital following a seizure at work
and another that occured while in the hospital emergency
department. While in the hospital ___ were evaluated by the
neurology team. ___ underwent an EEG (to monitor for brain
seizure activity) and lab work.
While in the hospital, ___ did well and were restarted on your
home seizure medications. There was no further evidence of
seizure activity either clinically or on EEG.
Things that can provoke or cause seizures include sleep
deprivation, stress, heavy alcohol use and missing doses of your
anti-seizure medication. Please avoid these activities to help
prevent future seizures.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10413783-DS-9 | 10,413,783 | 21,144,615 | DS | 9 | 2188-11-27 00:00:00 | 2188-12-01 18:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Amiodarone
Attending: ___.
Chief Complaint:
Breakthrough seizure, AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo man with a h/o epilepsy, afib, and a
resected meningioma who presents to the ED as a transfer after a
breakthrough seizure. He was at work at ___ ___, and had
a seizure during dinner break. Per OSH ED report, he had an
"unwitnessed seizure."
EMS was called and he was taken to ___. He was
loaded with 1000mg IV Keppra with a plan to discharge, but his
mental status did not return to baseline, with repetitive
speech, so he was transfered to ___ for a neuro eval. Per
report the ED, per the family, he typically has repetitive
speech and altered mental status prolonged for ___ days after a
breakthrough seizure. In the ___ ED, because of his h/o
anticoagulation, a NCHCT was obtained which was negative for an
acute bleed. His mental status improved somewhat in the ED and
on my eval he was able to tell me he was at work yesterday, on
dinner break at 4:30pm when he "felt off" like he was about to
have a seizure. He notified his co-worker and sat down. An
ambulance was called who brought him to OSH. The patient denies
LOC, though it is unclear how accurate this history is.
He presented in ___ with a similar presentation of a
breakthrough seizure at work, with a subsequent GTC in the ED,
followed by a prolonged post ictal period. His breakthrough
seizure at that time was felt to be from acute EtOH withdrawal
and missing a Keppra dose.
The patient is unable to answer questions about any recent
alcohol use or potential triggers for his breakthrough seizure
like infectious symptoms, decreased sleep, or missed AED doses.
At one point he became agitated, seemingly because he wasn't
understanding the questions I was asking. He tried to refuse the
assessment, but was amenable to a quick exam. Thus, PMH, SH, FH,
allergies, and meds were obtained from previous records.
Epilepsy clinic note from ___ (Dr. ___ describes his
typical seizure semiology as feeling shaky and dizzy, and
staring off w/out tonic-clonic movements. Another time his
seizure was described as his mind and speech became garbled with
LOC.
Review of Systems: unable to obtain because of mental status
Past Medical History:
- Left parietal meningioma s/p resection (___) c/b complex
partial seizures (seen by ___ prior, first seizure in
___
- Alcohol abuse
- Hypertension
- CAD s/p Promus stent x 2 to proximal/mid LAD ___
- Moderate chronic congestive heart failure
- Atrial fibrillation
- Atrial flutter ablation
- Type 2 Diabetes
- Dyslipidemia
- Obesity
Social History:
___
Family History:
Patient was adopted and does not know family history.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: 98.3 80 134/85 14 97% RA
General: easily agitated
HEENT: MMM, missing multiple teeth
Pulmonary: on RA
Cardiac: irregular
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Asleep, easily aroused with touch. Speech is
non-fluent. Patient is perseverative. Names items on stroke card
(except cannot name hammock and calls glove "teeth...hand") but
elaborates (i.e. "Key middle...cactus left..."). Difficulty
following comprehension and verbal instructions, instead needs
to mime me to complete exam. Cannot follow command to touch his
ear (gives me a confused look, makes no attempt to try). Does
not understand many of my questions and easily becomes
frustrated and agitated - tried to refuse my assessment/exam but
was redirectable. Cannot repeat (though doesn't seem to
understand the command to repeat). Does not attempt to describe
cookie jar picture, just mimics my action of pointing at it.
Speech was not dysarthric.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm bilaterally.
III, IV, VI: EOMI with a few beats of end gaze nystagmus. Had a
few seconds of rapid eye blinking twice during the exam.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop with symmetric upper and lower facial
musculature bilaterally
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: pt unable to understand this command - instead reaches to
grab my shoulders
XII: Tongue protrudes in midline with full ROM right and left
-Motor: Patient unable to follow directions for full motor exam.
Triceps, biceps, wrist extensors, finger extensors, finger
flexors, and IPs were full strength bilaterally. He
flexed/extended his feet repeatedly with good strength. action
tremor present bilat.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 *
R 2 2 2 * 2
- Toes were withdraw bilaterally.
*pt wouldn't relax for proper testing
-Sensory: Endorses no deficits to light touch throughout. Unable
to cooperate with temperature sensation testing.
-Coordination: No dysmetria touching my finger bilaterally.
-Gait: deferred given mental status and agitation
DISCHARGE PHYSICAL EXAMINATION:
Aphasia completely resolved.
Pertinent Results:
ADMISSION LABS:
___ 01:42AM BLOOD WBC-9.5 RBC-4.54* Hgb-13.8 Hct-41.7
MCV-92 MCH-30.4 MCHC-33.1 RDW-13.0 RDWSD-43.7 Plt ___
___ 01:42AM BLOOD Neuts-61.4 ___ Monos-8.6 Eos-3.2
Baso-1.3* Im ___ AbsNeut-5.84 AbsLymp-2.39 AbsMono-0.82*
AbsEos-0.30 AbsBaso-0.12*
___ 01:47AM BLOOD ___ PTT-40.9* ___
___ 01:42AM BLOOD Plt ___
___ 01:42AM BLOOD Glucose-114* UreaN-13 Creat-0.8 Na-139
K-4.3 Cl-99 HCO3-27 AnGap-17
___ 01:42AM BLOOD ALT-29 AST-41* AlkPhos-72 TotBili-0.6
___ 01:42AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:50AM BLOOD Lactate-2.2*
___ 05:15AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:15AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 05:15AM URINE CastHy-22*
___ 05:15AM URINE Mucous-FEW
___ 05:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
IMAGING:
1. CT HEAD ___:
No evidence of infarction, hemorrhage or fracture. Post left
parietal craniotomy and meningioma resection, with unchanged
encephalomalacia in the left parietal lobe.
2. CXR ___:
No acute cardiopulmonary abnormality. Possible COPD.
EEG:
___: Abnormal continuous video EEG study due to the left
temporal
epileptiform discharges with a broad parietotemporofrontal field
consistent with a focus of epileptogenicity in this region.
There were also bursts of focal left posterior quadrant slowing.
There were no electrographic seizures or pushbutton activations.
Brief Hospital Course:
___ is a ___ yo left handed man with a history of alcohol abuse,
AFIB, and epilepsy, who presented to OSH with a breakthrough
seizure and transferred to BI with subsequent inability to
understand speech. From prior notes his post ictal periods are
characterized by inability to communicate, specifically
understand speech. On initial exam he was aphasic with poor
comprehension. He was admitted to the epilepsy service to assess
on cvEEG for possible subsequent seizures.
1. Neuro: Epilepsy with breakthrough seizure. He was loaded with
keppra 1000mg prior to transfer to our service. He reports not
missing his keppra doses, but notes less sleep recently as he is
stressed at work. He notes that beer triggers his seizures and
he had a "couple of drinks on ___ prior to his seizure.
NCHCT was done in the ED and found no evidence of infarction,
hemorrhage or fracture. Evidenced he is post left parietal
craniotomy and meningioma resection, with unchanged
encephalomalacia in the left parietal lobe. He was monitored on
cvEEG, which was per report: "Abnormal continuous video EEG
study due to the left temporal epileptiform discharges with a
broad parietotemporofrontal field consistent with a focus of
epileptogenicity in this region. There were also bursts of focal
left posterior quadrant slowing." We have continued his home
keppra 1500mg PO bid. He was also given thiamine, and placed on
CIWA protocol which was later discontinued as he did not score.
2. CV: AFIB on dofetilide. Continued his home dose. Monitored on
telemetry while in house.
3. TOX/METAB: Checked LFT's which were WNL. Urine and serum tox
screens were negative
4. ID: UA found with 1 WBC, 8 RBCs, few bacteria. Completely
asymptomatic. CXR with no acute cardiopulmonary abnormality.
Possible COPD.
Transitional issues:
- Should schedule a follow up appointment with his PCP ___
___ weeks.
- Will follow with his outpatient neurologist Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 1500 mg PO BID
2. Nadolol 40 mg PO QID
3. Dofetilide 250 mcg PO Q12H
4. Simvastatin 80 mg PO QPM
5. Digoxin 0.25 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Dabigatran Etexilate 150 mg PO BID
8. Magnesium Oxide 400 mg PO TID
9. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Dabigatran Etexilate 150 mg PO BID
2. Digoxin 0.25 mg PO DAILY
3. Dofetilide 250 mcg PO Q12H
4. FoLIC Acid 1 mg PO DAILY
5. LeVETiracetam 1500 mg PO BID
6. Magnesium Oxide 400 mg PO TID
7. Nadolol 40 mg PO QID
8. Simvastatin 80 mg PO QPM
9. Aspirin 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after a breakthrough seizure.
After being seen at another hospital and getting an extra dose
of Keppra, you were transferred here. You were admitted to the
neurology service for concerns of trouble speaking which was
likely a result of the seizure. We have monitored you on EEG,
and found you stable with no continued seizures. You will follow
with your outpatient neurologist Dr. ___ in two weeks as
listed below.
We made no changes to your medications.
Instructions:
1. Please continue all your medications as directed by this
document.
2. Please keep your follow up appointments as below.
3. Please do not hesitate to call with questions.
Per ___ state law, you are not to drive for six months
following a seizure.
It was a pleasure taking care of you during this hospital stay.
Followup Instructions:
___
|
10413870-DS-8 | 10,413,870 | 29,801,928 | DS | 8 | 2170-05-06 00:00:00 | 2170-05-08 21:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
pre-syncope, workup for ?aortitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female w/ hx of PVD, infrarenal AAA, carotid
stenosis, CKD, HTN who presented to ___ last night for
near syncopal episode and transferred here for vascular
consultation for suspected aortitis. Medicine consulted for
evaluation for pre syncope.
Of note, patient was recently hospitalized here
___ for acute blood loss and found to have a small
duodenum ulcer thought to be secondary to NSAIDs use. Reports
feeling lightheaded after standing from a seated position. She
also felt warm and appeared pale (per her husband) before
falling backwards. No loss of consciousness. +head strike on
rug. Denies any chest pain, palpitations, sob before symptoms.
No abnormal movements, confusion, or slurred speech during or
after the event. +dry heaving prior to the episode. Patient also
took her daily atenolol and amlodipine one hour prior to fall.
No hx of prior falls, but does have a history of lightheadedness
when standing from a sitting position.
Denies new medications, chills, URI like symptoms, urinary
symptoms, vomiting, diarrhea, abdominal pain, bloody stools,
melena.
On arrival to the outside hospital, she was noted to be
hypotensive with systolic blood pressures in the ___ to ___. She
had trace heme positive stool with no evidence of melena.
Laboratory significant for a creatinine of 2.7, consistent with
acute on chronic kidney injury, and stable hematocrit. CT
imaging showed a stable infrarenal abdominal aortic aneurysm,
but with new stranding suggestive of aortitis.
In ED, blood pressures were in the 100s/60s (usually 110s-120s
systolic). Received IVF bolus.
Currently, feeling well and denies any symptoms.
Past Medical History:
PVD
Infrarenal AAA
Carotid Stenosis
Benign Hypertension
Hyperlipdiemia
CKD
GERD
COPD
Social History:
___
Family History:
Father died at ___ from MI
Mother died at ___ from SLE
No known family history of colon cancer.
Physical Exam:
ON ADMISSION:
-------------
Vitals: T 100.4, BP 146/100, HR 95, RR 24, O2 sat 99% RA
General: comfortably laying in bed, NAD
HEENT: PERRL, EOMI, OP clear, dry MM
CV: RRR, ___ holosystolic murmur best heard at ___, no g/r
Lungs: decreased breath sounds throughout, mild bibasilar
crackles, no wheezes
Abdomen: +BS, NT, ND, no guarding/rebound
Ext: no c/c/e, toes feel cool, diminished pulses bilaterally
Neuro: A&Ox3, sensation to light touch normal throughout, 4+/5
strength in lower extremities, CNs grossly intact, normal FTN,
symmetric smile
Skin: no rashes
AT DISCHARGE:
-------------
VS - Tmax 98.0, HR 77(70-80s), BP 97-147/63-74, 100% on RA
General: comfortably laying in bed, NAD
HEENT: PERRL, EOMI, OP clear, dry MM
Neck: supple, no LAD, however, carotid bruits noted b/l
CV: RRR, ___ holosystolic murmur best heard at ___, no g/r
Lungs: decreased breath sounds throughout, mild bibasilar
crackles, no wheezes
Abdomen: +BS, NT, ND, no guarding/rebound
Ext: no c/c/e, toes feel cool, diminished pulses bilaterally
Neuro: A&Ox3, sensation, strength intact, symmetric smile
Skin: no rashes
Pertinent Results:
LABORATORY DATA ON ADMISSION:
___ 08:30AM WBC-10.6 RBC-3.76* HGB-10.9* HCT-32.7* MCV-87
MCH-29.0 MCHC-33.3 RDW-14.9
___ 08:30AM PLT COUNT-116*
___ 08:30AM NEUTS-86.5* LYMPHS-8.3* MONOS-4.2 EOS-0.9
BASOS-0.1
___ 08:18AM LACTATE-1.8
___ 08:30AM GLUCOSE-109* UREA N-22* CREAT-2.7*#
SODIUM-137 POTASSIUM-3.1* CHLORIDE-106 TOTAL CO2-18* ANION
GAP-16
___ 08:30AM CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-2.1
___ 08:30AM CK-MB-4 cTropnT-0.02*
___ 07:20PM CK-MB-2 cTropnT-0.02*
LABORATORY DATA AT DISCHARGE:
___ 06:24AM BLOOD WBC-4.2 RBC-3.24* Hgb-9.2* Hct-29.1*
MCV-90 MCH-28.5 MCHC-31.8 RDW-15.1 Plt ___
___ 06:24AM BLOOD Plt ___
___ 06:24AM BLOOD Glucose-89 UreaN-11 Creat-2.3* Na-139
K-3.7 Cl-110* HCO3-21* AnGap-12
___ 06:24AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9
IMAGING REPORTS THIS ADMISSION:
2D TTE ___:
No structural cardiac cause of syncope identified. Mild
symmetric left ventricular hypertrophy with normal biventricular
cavity size and regional/global systolic function. Elevated
PCWP.
MRA & MRI ABDOMEN W&/WO CONTRAST ___:
Focal infrarenal anterior saccular aneurysm, with minimal
interval increase is transverse dimension (now 2.8 x 2.4 cm).
This aneurysm is partially thrombosed, a new finding as compared
to ___, with could account for surrounding periaortic
edema. Consideration should be given to mycotic aneurysm or
infected thrombus, if clinical or laboratory findings of
infection are present. Imaging appearance is not suggestive of
large vessel vasculitis given lack of wall thickening and edema.
RENAL ULTRASOUND ___:
1. No evidence of hydronephrosis, stones, or perinephric
abnormality
bilaterally.
2. Mildly echogenic kidneys likely reflect underlying medical
renal disease.
3. Bilateral renal cysts.
4. Cholelithiasis.
Brief Hospital Course:
___ hx of PVD, infrarenal AAA, carotid stenosis, CKD, HTN and
COPD, p/w presyncopal episode, found to have ?aortitis on
imaging and new F.U.O.
# FEVER: Workup for fevers including UA, blood cultures, and CXR
have been unrevealing, no constitutional sx's. Echo without
evidence of endocarditis. There is concern for aortitis due to
findings in CT abdomen. Etiology of aortitis includes infectious
(in particular syphilis, staph and salmonella, although this
usually occurs in ascending aorta) vs. autoimmune causes, given
elevated CRP and concomittant anemia and renal dysfunction, vs.
vasculitis vs. connective tissue disease. Patient has risk
factors for aortic infection due to atherosclerosis. Given
concern for aortitis, f/u imaging appears to be warranted.
However, due to her CKD, would recommend MRA rather than CTA.
MRA showed fat stranding, clot in aneurysm and mycotic
appearance. ID recommending quant gold for TB rule out and
possible inpatient PET scan. Deferred antibiotic treatment given
her improved and stable clinical picture. Drew daily blood cx
until the date the first returned negative; these have been
consistently negative to date. Trended her fever curve, however,
she remained persistently afebrile for over 96 hours. Plan to
continue to follow-up with ID as outpatient and for patient to
monitor for fevers at home, as well as PET scan as outpatient.
AI workup showed negative ___ and ANCA. Rheumatology was
consulted, and did not believe that her current presentation was
consistent with an underlying rheumatologic disorder.
# AORTIC ANEURYSM WITH CONCERN FOR AORTITIS: see above for
differential and workup. Vascular surgery evaluated the patient
for concern for aortitis and determined that there was no role
for surgical intervention and signed off. Please see above for
workup of aortitis.
# ANEMIA: hemolysis labs: negative, maintained active type and
screen, stools were guaiacked and were consistently negative for
occult blood.
# ___ ON CKD: Cr up to 2.6 from baseline 1.7, not responsive to
fluids, urine with large blood but one RBC, and mildly elevated
CK, considered possibility of rhabdo in setting of recent fall.
ATN also a possibility given episode of mhypotension and no
response to IVF. Initially held statin given concern for rhabdo,
this was restarted at time of discharge. Cr had steadily trended
down by time of discharge to 2.3.
CHRONIC MEDICAL CONDITIONS:
# HYPERTENSION: held home amlodipine and atenolol, given she was
not hypertensive and initially hypotensive/ orthostatic at time
of discharge.
# HYPERLIPIDEMIA: held home rosuvastatin pending CK; this
medication was restarted at time of discharge.
# GERD: continued home pantoprazole
# COPD: continued home Fluticasone-Salmeterol and Tiotropium
# CKD: continued to trend Cr, electrolytes
RESOLVED ISSUES:
----------------
# HYPOTENSION: Resolved. likely orthostatic from deconditioning
from her hospitalization one month ago, in combination with
decreased PO intake and weight loss while continuing on same
anti-hypertensive medication doses. Continued to monitor. Held
home BP meds during admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
2. Rosuvastatin Calcium 20 mg PO QPM
3. Tiotropium Bromide 1 CAP IH DAILY
4. Amlodipine 10 mg PO DAILY
5. Atenolol 50 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
2. Pantoprazole 40 mg PO Q12H
3. Tiotropium Bromide 1 CAP IH DAILY
4. Rosuvastatin Calcium 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Concern for Aortitis (Infectious versus Inflammatory)
Fever of Unknown Origin
SECONDARY DIAGNOSES:
Peripheral vascualr disease, carotid stenosis, HTN,
Hyperlipidemia, chronic kidney disease, COPD, GERD, anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you during your hospital stay
at ___.
You were transferred to us from an outside hsopital when you
presented with low blood pressures, which corrected with IV
fluids. A scan there revealed inflammation around your known
aortic aneurysm, for which you were transfered here for further
evaluation.
Our vascular surgeons evaluated you, and did not think you were
bleeding from your aneurysm, or that the clots found in your
aneurysm would cause the fevers that you developed here for two
days. However, the appearance of your aneurysm was concerning
for potential infection, which could have been the cause of your
fevers that have now resolved. You were seen by the Infectious
Disease physicians, with whom you should follow-up as an
outpatient. (You were also seen by Rheumatologists, who did not
think your fevers were due to an inflammatory condition.)
You should follow up at your previously scheduled vascular
surgery appointments to monitor your aneurysm. You must also
make an appointment with Infectious Disease (at ___, or
here at ___. Please also make an appointment with your
Primary Care Physician this week, and ask them to order a PET
scan to further evaluate your aneurysm for infection.
Please take your temperature regularly at home, and if you
develop a fever at any time (greater than 100.5 F), call your
primary care doctor or come to the emergency department.
Your Primary Care Physician should also know that while you were
in the hospital, we held your home blood pressure medications
for light-headedness. Your primary care doctor can restart these
medications when appropriate.
We wish you the very best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10414036-DS-5 | 10,414,036 | 28,967,154 | DS | 5 | 2147-08-29 00:00:00 | 2147-08-29 17:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
hydrochlorothiazide / ampicillin
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___. Ultrasound-guided aspiration of a right hepatic lobe
hypoechoic lesion. 4 cc of frank pus were aspirated. Specimen
was sent for microbiology analysis.
2. Placement of ___ 8 ___ drainage catheter within a left
lower pelvis contained diverticular abscess. Purulent material
was aspirated and sent for microbiology analysis.
___ Ultrasound-guided therapeutic drainage of left hepatic
lobe 4cm abscess with removal of 25cc pus. Additional 1.5-2.5cm
abscesses remain. 8fr drain ___ place.
___ PICC line placed, right arm
History of Present Illness:
Mrs. ___ is a ___ year old female with a history of renal
cell ca, bladder ca, p/w fever to 103.9. She reports having had
3 days of watery, nonbloody diarrhea last week and intermittent
fevers at home since that time. She presented today to her PCP,
who referred her to the ED for CT evaluation.
She denies associated symptoms - specifically nausea, vomiting,
dysuria, shortness of breath, chest pain, dark urine, jaundice,
or itching. She does endorse some anorexia with less PO intake
over the past 7 days. Her last bowel movement was this morning
prior to presentation and was normal by her report. She is
passing flatus. Denies prior episodes.
Her last colonoscopy was ___ ___, but was not complete secondary
to severe pelvic adhesive disease. She reports that a
subsequent virtual colonoscopy was normal.
Past Medical History:
Past Medical History: bladder ca ___ s/p BCG/interferon, RCC s/p
partial L nephrectomy (followed at ___, osteoporosis,
multinodular goiter, endometriosis
Past Surgical History: partial L nephrectomy ___, open pelvic
exploration for endometriosis, tonsillectomy
Social History:
___
Family History:
Dementia, pharyngeal ca, liver ca
Physical Exam:
On admission:
Vitals: 103.9 105 121/67 16 93%
GEN: A&Ox3, pleasant, nontoxic, NAD.
HEENT: No scleral icterus, mucus membranes moist
CV: Regular
PULM: Clear
ABD: Soft, mildly distended but nontender. Palpable
inflammatory
mass ___ LLQ. L flank incisional hernia soft, reducible,
nontender. Well healed L flank and low transverse incisions.
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused. Palpable DP
bilaterally.
On discharge:
VS: T98.6, 76, 149/77, 14, 94% on room air.
Pertinent Results:
___ 06:00AM BLOOD WBC-11.7* RBC-3.73* Hgb-11.7* Hct-34.8*
MCV-93 MCH-31.4 MCHC-33.6 RDW-12.9 Plt ___
___ 07:06AM BLOOD WBC-16.3* RBC-3.82* Hgb-12.2 Hct-35.9*
MCV-94 MCH-31.9 MCHC-34.0 RDW-13.1 Plt ___
___ 06:00AM BLOOD WBC-18.8* RBC-3.38* Hgb-10.8* Hct-31.5*
MCV-93 MCH-32.0 MCHC-34.4 RDW-13.1 Plt ___
___ 06:25AM BLOOD WBC-19.4* RBC-3.79* Hgb-12.0 Hct-35.8*
MCV-95 MCH-31.6 MCHC-33.5 RDW-12.6 Plt ___
___ 08:45AM BLOOD WBC-18.5* RBC-3.67* Hgb-12.0 Hct-33.9*
MCV-92 MCH-32.6* MCHC-35.3* RDW-13.0 Plt ___
___ 05:55AM BLOOD WBC-15.7* RBC-3.86* Hgb-12.4 Hct-36.1
MCV-94 MCH-32.2* MCHC-34.4 RDW-12.7 Plt ___
___ 02:00PM BLOOD WBC-22.5*# RBC-4.18* Hgb-13.4 Hct-38.5
MCV-92 MCH-31.9 MCHC-34.7 RDW-12.8 Plt ___
___ 02:00PM BLOOD Neuts-91.5* Lymphs-3.8* Monos-3.8 Eos-0.7
Baso-0.2
___ 06:25AM BLOOD ___ PTT-29.0 ___
___ 06:00AM BLOOD Glucose-133* UreaN-4* Creat-0.5 Na-136
K-4.6 Cl-102 HCO3-24 AnGap-15
___ 07:06AM BLOOD Glucose-143* UreaN-4* Creat-0.6 Na-133
K-4.9 Cl-100 HCO3-25 AnGap-13
___ 06:00AM BLOOD Glucose-157* UreaN-4* Creat-0.5 Na-134
K-3.9 Cl-102 HCO3-24 AnGap-12
___ 06:25AM BLOOD Glucose-131* UreaN-6 Creat-0.6 Na-134
K-3.8 Cl-97 HCO3-26 AnGap-15
___ 05:00PM BLOOD Na-132* K-3.5 Cl-98
___ 08:45AM BLOOD Glucose-218* UreaN-9 Creat-0.6 Na-131*
K-3.5 Cl-96 HCO3-22 AnGap-17
___ 05:55AM BLOOD Glucose-144* UreaN-10 Creat-0.6 Na-133
K-3.9 Cl-96 HCO3-25 AnGap-16
___ 02:00PM BLOOD Glucose-178* UreaN-21* Creat-1.1 Na-128*
K-3.9 Cl-88* HCO3-24 AnGap-20
___ 02:00PM BLOOD ALT-28 AST-32 AlkPhos-87 TotBili-1.8*
DirBili-1.1* IndBili-0.7
___ 06:00AM BLOOD Calcium-8.5 Phos-4.5# Mg-1.8
___ 07:06AM BLOOD Calcium-9.2 Phos-1.6* Mg-1.5*
___ 06:00AM BLOOD Calcium-8.2* Phos-1.7* Mg-1.7
___ 08:45AM BLOOD CEA-9.6* AFP-2.3 CA125-29
___ 05:55AM BLOOD CEA-10*
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND ___ SHORT
CHAINS.
Reported to and read back by ___ ___ 21:32
___.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP. SPARSE GROWTH.
STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE
GROWTH.
SECOND MORPHOLOGY.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 2:00 pm ABSCESS Source: ___ abscess.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CHAINS.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so ___
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
GRAM POSITIVE COCCUS(COCCI). MODERATE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
Time Taken Not Noted ___ Date/Time: ___ 5:43 pm
ABSCESS LEFT LOBE HEPATIC ABSCESS.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
___ SHORT CHAINS.
Reported to and read back by ___ ON ___ @ 9
___.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary):
STREPTOCOCCUS SPECIES. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
IMAGING:
___ Chest (PA and lat)
Mild bibasilar atelectasis/scarring. Otherwise, no acute
cardiopulmonary process.
___ CT abdomen and pelvis with contrast
1. Marked thickening of the sigmoid colon with contained
perforation
resulting ___ 2 ___ fluid collections. These collections
are not
amenable to percutaneous drainage. Perforation may be secondary
to acute
diverticulitis though ___ underlying malignancy is not excluded
(given findings ___ the liver - see impression #2).
2. Liver hypodense lesions (at least 6) measuring up to 3.4 cm,
raise concern for metastasis, less likely abscesses. Biopsy
advised.
3. Multiple bilateral renal hypodensities, the majority are
likely simple cysts. Several are increased ___ size from
___ of these appears hyperdense and new prior prior. MRI
may be performed to further assess.
4. Left adrenal adenoma, previously characterized as adenoma,
appears to be slowly increasing ___ size compared to ___ CT.
This too can be further
assessed with MRI.
5. Possible small hepatic vein thrombus ___ the right hepatic
lobe posteriorly
(2:19).
___ Liver/gallbladder U/S
Ultrasound-guided therapeutic drainage of left hepatic lobe 4cm
abscess with removal of 25cc pus. Additional 1.5-2.5cm abscesses
remain. 8fr drain ___ place. No complications.
___ Echocardiogram
The left atrium is normal ___ size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild to moderate global left ventricular
hypokinesis (LVEF = 40 %). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No vegetations seen
Brief Hospital Course:
Mrs. ___ presented to ___ on ___ with complaints of 3
days of watery, nonbloody diarrhea the week prior to admission
and intermittent fevers at home at the time of admission. She
underwent a CT of the abdomen and pelvis which revealed
perforated diverticulitis with two ___ fluid
collections. It also showed new liver abscesses since her last
scanning from ___ ___ ___. The patient was kept NPO (except her
home medications) and given IV fluids. She was started on Cipro
and Flagyl during this time. Her blood counts and metabolic
panel was checked daily. Electrolytes were repleted as
necessary while the patient was NPO. With a history of cancer,
her CEA was checked, revealing ___ elevated level of 9.6.
On hospital day two, Mrs. ___ had intermittent periods of
hypotension with systolic pressures ___ the high ___. She was
asymptomatic during these episodes. She was not orthostatic. A
small fluid bolus was administered with had little effect on her
pressure. He blood pressure normalized thereafter. Her home
atenolol was divided into two doses and given twice daily versus
daily. Her home lisinopril was never started. Because the same
issue arose on hospital day three, Mrs. ___ atenolol was
discontinued.
On ___, Mrs. ___ underwent aspiration of a right hepatic
hypodense lesion and
placement of ___ 8 ___ drainage catheter within her left
diverticular, perforated contained abscess. She tolerated the
procedure well. Specimens were sent for culture.
Ultrasound-guided therapeutic drainage of left hepatic lobe 4cm
abscess with removal of 25cc pus. Additional 1.5-2.5cm abscesses
remain. 8fr drain ___
place. There were no complications.
Since both of those procedures, Mrs. ___ liver culture was
positive for streptococcus anginosus, which is penicillin
sensitive. Her ___ abscess had mixed bacterial flora.
Infectious Disease was consulted. Their recommendation was that
Zosyn was discontinued and the patient be started on
ceftriaxone. Metronidazole was continued while inpatient. ___
echocardiogram was also obtained to rule out infectious valvular
disease/dysfunction. The echocardiogram showed no vegetations.
On ___ a PICC line was inserted for long-term antibiotics.
The initial insertion by the IV RN was shown to be ___ poor
position, so the patient was taken to radiology on the same day
for repositioning, which was successful.
As her abdominal pain subsided and she continued to have bowel
function, Mrs. ___ was resumed on a regular diet on ___.
She tolerated it well without issue. Her IV fluids were
discontinued. She had no issues voiding.
Mrs. ___ was prepared for discharge home on ___. Per
Infectious Disease recommendations, she will continue on
ceftriaxone for a total of four weeks at home. ___ infusion RN
will visit the patient at home where she can be educated on her
daily infusions. ___ nursing was ordered as well for monitoring
of her drain sites and outputs. The patient was instructed to
follow up with ID, her PCP (for blood pressure management and
general follow-up) and ACS.
At the time of discharge, Mrs. ___ was afebrile,
hemodynamically stable and ___ no acute distress.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO Frequency is Unknown
Take every other week per prior home regimen.
2. Atenolol 25 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 1 vial IV daily Disp #*28 Vial Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. Lisinopril 20 mg PO DAILY
6. Alendronate Sodium 70 mg PO EVERY OTHER WEEK
Take every other week as prescribed previously.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
- Complicated diverticulitis
- Pericolonic abscess s/p drainage
- Hepatic abscesses s/p drainage
- Intermittent asymptomatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ on
___ with complaints of fevers and diarrhea. On further
evaluation, you were found to have perforated diverticulitis
with ___ abscess formation near/around the affected bowel. You
also were found to have abscesses ___ your liver. Both
conditions required drainage of those infectious sites. Due to
the type of bacteria present ___ the drainage, you were started
on IV antibiotics while inpatient.
You are now being discharged home with ___ and infusion
services. You will continue on IV antibiotics for the next four
weeks. ___ infusion nurse ___ visit you at home to assist ___
administering the necessary medications.
Please follow-up with the Infectious Disease Clinic at the
appointment noted below. You will continue on antibiotics until
they direct you otherwise.
Please note that during this admission, you became hypotensive
(low blood pressure) intermittently. Your home Atenolol and
Lisinopril were stopped. You should resume all other home
medications. You have since been started on your Lisinopril
ONLY. Please see Dr. ___ at the appointment below for further
instruction about resuming your home blood pressure medications.
GENERAL DRAIN CARE:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid ___ the drain. ___
the doctor, ___, or ___ nurse if the amount
increases significantly or changes ___ character. Be sure to
empty the drain frequently. Record the output daily and bring
those measurements with you to your follow-up visit to the ___
clinic (see below).
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself ___
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
PICC LINE Instructions:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE ___ THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
___
|
10414036-DS-7 | 10,414,036 | 25,052,511 | DS | 7 | 2148-02-04 00:00:00 | 2148-02-06 21:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
hydrochlorothiazide / ampicillin
Attending: ___.
Chief Complaint:
Peristomal pain
Major Surgical or Invasive Procedure:
CT-guided drain placement in a left lower quadrant/pelvic fluid
collection
History of Present Illness:
___ s/p ___ procedure for perforated sigmoid
diverticulitis with failed medical management returns with
peristomal pain and one bowel movement this morning. Over the
last two weeks she has experienced intermittent ___ stomal pain
worse over the last two days. She continues to have stomal
output without blood. She has not experienced any fevers,
chills, shortness of breath, cough. She continues to tolerate a
regular diet.
Past Medical History:
Past Medical History: bladder ca ___ s/p BCG/interferon, RCC s/p
partial L nephrectomy (followed at ___, osteoporosis,
multinodular goiter, endometriosis
Past Surgical History: partial L nephrectomy ___, open pelvic
exploration for endometriosis, tonsillectomy
Social History:
___
Family History:
Dementia
Pharyngeal cancer
Liver cancer
Physical Exam:
Admission Physical Exam:
Vitals: 97.7 91 ___ 99% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, minimally tender around stoma, no
rebound or guarding, normoactive bowel sounds, no palpable
masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Discharge Day Physical Exam:
Vitals: AF, VSS
Gen: Caucasian female sitting up in bed in NAD, drain and
colostomy bag in place.
HEENT: PERRL, EOMI. No scleral icterus. Moist mucous membranes.
CV: RRR, no M/R/G.
Resp: Lungs with distant breath sounds, no w/r/r.
Abd: Soft, nondistended, nontender. Colostomy with brown stool
output. ___ drain in place without any surrounding W/E/D.
Pertinent Results:
___ 01:50PM BLOOD WBC-17.0*# RBC-4.21 Hgb-12.4 Hct-38.4
MCV-91 MCH-29.4 MCHC-32.3 RDW-13.2 Plt ___
___ 01:50PM BLOOD Glucose-115* UreaN-10 Creat-0.5 Na-136
K-4.2 Cl-98 HCO3-24 AnGap-18
___ 01:50PM BLOOD ALT-36 AST-28 AlkPhos-104 TotBili-0.7
___ 06:55PM BLOOD Lactate-1.1
___ 06:34AM BLOOD WBC-9.4 RBC-3.53* Hgb-10.3* Hct-32.1*
MCV-91 MCH-29.3 MCHC-32.2 RDW-13.2 Plt ___
___ 06:34AM BLOOD Glucose-98 UreaN-5* Creat-0.4 Na-136
K-3.7 Cl-100 HCO3-26 AnGap-14
Brief Hospital Course:
Ms. ___ was admitted to the Acute Care General Surgery
service on ___ with peristomal pain concerning for a fluid
collection in the post-operative setting. CT imaging of the
abdomen/pelvis did reveal a left-sided pelvic abscess measuring
6.9 x 2.2 x 3.6 cm and sub-optimal uptake of PR contrast into
the rectal stump, but no evidence of anastomotic leak. The
patient was given IV fluids and started on ciprofloxacin and
flagyl for appropriate antibiotic coverage. On HD#2 she
underwent ___ drainage of approximately 25cc purulent,
foul-smelling fluid; subsequently, the ___ catheter
was attached to an external drainage bag. Fluid gram stain was
consistent with a polymicrobial infection containing gram
negative rods and gram positive cocci in pairs, chains and
clusters. Cultures grew sparse Enterococcus species and gram
positive cocci. The patient tolerated the procedure without any
complications and was advanced to a full diet without
complications. She remained afebrile with significant pain
relief, and returned to her normal level of function by day of
discharge. The patient was discharged home on HD# in improved
condition with a 14-day course of ciprofloxacin and Flagyl. She
will follow-up in the ___ in two weeks' time.
Medications on Admission:
Creon 6,000-19,000-30,000 daily
Zenpep 20,000-68,000-109,000 TID with meals
Lisinopril 20 mg daily
Lorazepam 1 mg daily
Aspirin 81 mg daily
Calcium Citrate + D 315 mg-200 unit BID
AquADEKs 100 mcg-10 mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Aspirin 81 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*22 Tablet Refills:*0
4. Creon 12 1 CAP PO TID W/MEALS
5. Lisinopril 20 mg PO DAILY
6. Lorazepam 1 mg PO HS:PRN anxiety
7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*33 Tablet Refills:*0
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
9. Saline Wound Wash (benzethonium chloride;<br>sodium chloride)
0.9 % miscellaneous daily
Please use saline to flush drain once daily.
RX *sodium chloride [Saline Wound Wash] 0.9 % Please use normal
saline to flush drain Daily Disp #*1 Liter Refills:*0
10. Ondansetron 4 mg PO/NG Q8H:PRN Nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Pelvic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted to the General Surgery service at ___ for
management of peristomal pain. Your evaluation showed a fluid
collection close to your previous surgical site, concerning for
an abscess. A drain was placed in this area by Interventional
Radiology. Here are some general post-drain instructions to
follow:
DRAIN CARE:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or ___ strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10414036-DS-8 | 10,414,036 | 24,460,783 | DS | 8 | 2148-03-23 00:00:00 | 2148-03-23 14:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
hydrochlorothiazide / ampicillin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F w/ hx of ___ for perf diverticulitis in ___ c/b
intraabdominal abscess s/p ___ drain placement. Drain was d/c'd
in
the middle of ___, she has been doing well since then.
Mrs. ___ was in her usual state of health until yesterday
when she developed severe epigastric abdominal pain, radiated to
her back, associated with nausea and non bilious emesis.
Denies fever, functioning ostomy whit out change in output.
Patient with new diagnosis of atrophic pancreas, unknown
etiology, recently had a ___ be follow by GI.
Past Medical History:
Past Medical History: bladder ca ___ s/p BCG/interferon, RCC s/p
partial L nephrectomy (followed at ___, osteoporosis,
multinodular goiter, endometriosis
Past Surgical History: partial L nephrectomy ___, open pelvic
exploration for endometriosis, tonsillectomy, ___
Social History:
___
Family History:
Dementia
Pharyngeal cancer
Liver cancer
Physical Exam:
Vitals: 97.7 53 129/64 16 97%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses. Midline incision
without hernia, ostomy with + stool and gas. No tenderness to
palpation
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 03:42AM BLOOD WBC-20.6*# RBC-4.57 Hgb-13.3 Hct-40.8
MCV-89 MCH-29.1 MCHC-32.6 RDW-13.9 Plt ___
___ 07:40AM BLOOD WBC-5.5# RBC-3.89* Hgb-11.1* Hct-34.4*
MCV-88 MCH-28.6 MCHC-32.3 RDW-13.9 Plt ___
___ 03:42AM BLOOD Glucose-139* UreaN-17 Creat-0.6 Na-140
K-3.8 Cl-101 HCO3-26 AnGap-17
___ 07:40AM BLOOD ALT-21 AST-20 AlkPhos-74 Amylase-34
TotBili-0.8
___ 07:40AM BLOOD Lipase-8
___ 03:42AM BLOOD Albumin-4.4
___ 07:40AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.7
___ 04:46AM BLOOD Lactate-1.0
___ 06:15AM URINE Color-Straw Appear-Clear Sp ___
___ 06:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 5:52 AM
1. Ill-defined hypodensities in the pelvis, which could reflect
residual
phlegmonous changes/abscess, improved when compared to prior
examination.
Further evaluation with rectal contrast could be considered for
better
delineation.
2. Mild gallbladder wall thickening and prominent CBD, measuring
up to 7 mm.
3. Stable left adrenal gland adenoma.
4. Hyperdense complex left renal cyst, as seen before for which
MRI can be obtained to further evaluate.
Brief Hospital Course:
Ms. ___ was admitted to the Acute Care Surgery service at
___ with abdominal pain, a
white blood cell count of 20, and a pelvic phlegmon on CT. She
was kept NPO, given IVF, and started on antibiotics. Upon
starting antibiotics, the patient's pain improved.
On HD 2, the patient's leukocytosis had completely resolved. She
was started on clears, which she tolerated, and then advanced to
a regular diet. She was switched to oral medications. Given the
patients lack of symptoms, completely normal exam, and stable
vital signs, the patient was discharged to home. She will
complete 2 weeks of antibiotics. She will follow up with us in
clinic as scheduled. She expressed understanding that should she
develop any abdominal pain, fevers, or nausea/vomiting she
should call the clinic or return to the emergency department.
Medications on Admission:
1. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral daily
2. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit
oral TID
with meals
3. Lisinopril 20 mg PO DAILY
4. Lorazepam 1 mg PO HS:PRN anxiety
5. Aspirin 81 mg PO DAILY
6. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral BID
7. AquADEKs (multivit-min-FA-coenzyme Q10) 100-10 mcg-mg oral
daily
Discharge Medications:
1. Creon (lipase-protease-amylase) 6,000-19,000 -30,000 unit
oral daily
2. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit
oral TID
with meals
3. Lisinopril 20 mg PO DAILY
4. Lorazepam 1 mg PO HS:PRN anxiety
5. Aspirin 81 mg PO DAILY
6. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral BID
7. AquADEKs (multivit-min-FA-coenzyme Q10) 100-10 mcg-mg oral
daily
8. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*28 Tablet Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pelvic phlegmon
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Acute Care Surgery service at ___
___ with infected intra-abdominal
fluid. You have responded well to antibiotics and are ready to
continue your recovery at home. You should call the clinic or
come back to the Emergency Department if you develop abdominal
pain, fevers, or nausea/vomiting.
You should resume your home medications. You should take the
antibiotics as prescribed for 2 weeks. You will follow up with
us in clinic as planned.
Followup Instructions:
___
|
10414307-DS-9 | 10,414,307 | 20,214,648 | DS | 9 | 2122-10-15 00:00:00 | 2122-10-17 10:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy ___
History of Present Illness:
___ is a ___ with a history of congestive heart
failure, who developed RUQ abdominal pain on ___ afternoon.
Staff at her her nursing facility ___) noted lethargy
and temperature of 100. Patient reported "pain on my right side
after eating ___ toast for breakfast." She was brought to
___ where initial lab work showed AST 381, ALT 340,
Tbili 1.4, lactate 1.1. RUQ U/S was done which demonstrated
acute cholecystitis. Patient became hypotensive with systolics
in the ___. This improved with NS bolus. She received 3g Unasyn
and was then transferred to ___ for further care.
In the ED, initial VS were: 98.3 64 108/59 16 98%2L
Labs were notable for:
- WBC 14.9 with 85% PMNs, hemoglobin 9.3 (baseline unknown).
- Sodium 130, BUN 29, Creatinine 1.1 (baseline unknown) with BUN
29, K 4.7 and phos 4.8
- AST 271, ALT 353, AP 198, Tbili 1.1, lipase 21 and albumin 3.2
- lactate 1.2
Imaging from ___ showed: 15mm shadowing gallstones in
the galbladder neck, gallbladder wall thickening and a small
amount of pericholecystic fluid and 3mm stone in CBD without CBD
dilitation
Surgery was called, as was ERCP team.
Recommendations were pending at time transfer.
She was given zosyn and tylenol.
On arrival to the FICU, patient denies abdominal pain at rest,
only on palpation. Denies chest pain, shortness of breath.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, constipation. No
recent change in bowel or bladder habits. No dysuria.
Past Medical History:
- Congestive heart failure
- CAD / MI
- COPD
- Depression
- Diverticulosis
Social History:
___
Family History:
- No known family history of cardiovascular disease, patient
does not know ___ medical history
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
==============================
VITAL SIGNS: T 98 BP 87/43 P 59 R 21 Sat 96% on 2L
GENERAL: Alert, oriented, no acute distress but wincing
throughout exam
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Decreased breath sounds bilateral lung bases, trace
crackles bilaterally, no wheezes
CV: Regular rate and rhythm, no murmurs/rubs/gallops
ABDOMEN: soft, tender to palpation in epigastrum and RUQ,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: + Foley draining dark urine
EXTR: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; trace bilateral calf erythema, tenderness left ___ toe,
bony deformity bilateral toes
NEURO: CN intact, strength & sensation intact
SKIN: warm, dry, no rashes or lesions
Discharge Exam:
Vitals: 98.9, 120/61, 67, 18, 93% RA
General: elderly, Caucasian female, sleeping on right side,
easily arousable, NAD, decreased hearing without hearing aid
HEENT: atraumatic, PERRL, anicteric sclerae, mmm, dentures in
place
Neck: No LAD, full ROM, no JVD
CV: RRR, II/VI systolic murmur loudest at LSB
Lungs: CTAB, slight dependent crackles
Abdomen: soft, nondistended, nontender to palpation, guarding to
deep palpation, negative ___ sign, no rebound
Ext: wwp, right knee pain with active movement, ok with passive
movement, warmer than left knee, no erythema or edema. Left foot
pain, left big toe tenderness, without erythema, swelling
Neuro: PERRLA, EOMI, face symmetric, tongue midline
Pertinent Results:
LABS ON ADMISSION:
==================
___ 05:24AM BLOOD WBC-14.9* RBC-3.24* Hgb-9.3* Hct-27.6*
MCV-85 MCH-28.7 MCHC-33.7 RDW-18.9* Plt ___
___ 05:24AM BLOOD Neuts-84.9* Lymphs-8.0* Monos-6.6 Eos-0.2
Baso-0.2
___ 05:24AM BLOOD ___ PTT-24.9* ___
___ 05:24AM BLOOD Glucose-100 UreaN-29* Creat-1.1 Na-130*
K-4.7 Cl-97 HCO3-24 AnGap-14
___ 05:24AM BLOOD Albumin-3.2* Calcium-8.1* Phos-4.8*
Mg-2.0
___ 05:24AM BLOOD Lipase-21
___ 05:40AM BLOOD Lactate-1.2
___ 03:44PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 08:00AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
___ 03:44PM URINE RBC-39* WBC-43* Bacteri-FEW Yeast-NONE
Epi-0
___ 08:00AM URINE RBC-10* WBC-53* Bacteri-MOD Yeast-NONE
Epi-1
Labs on Discharge:
___ 07:11AM BLOOD WBC-7.7 RBC-3.36* Hgb-9.4* Hct-29.1*
MCV-87 MCH-28.0 MCHC-32.3 RDW-18.8* Plt ___
___ 07:11AM BLOOD ___ PTT-26.0 ___
___ 07:06AM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-137
K-3.8 Cl-99 HCO3-28 AnGap-14
___ 07:11AM BLOOD ALT-185* AST-60* AlkPhos-168* TotBili-0.8
___ 03:35AM BLOOD ALT-259* AST-136* AlkPhos-176*
TotBili-0.9
___ 05:24AM BLOOD ALT-353* AST-271* AlkPhos-198*
TotBili-1.1
___ 07:06AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.7
MICRO:
========
-Urine Culture: No growth (FINAL)
Blood Culture Sensitivities from ___ ___ : E.coli
-Sensitive: Amikacin, Cefoxatine, Gentamycin, Imipenem, Pip/Tazo
-Intermediate: Amoxicillin/clavulanic acid
-Resistant: Ampicillin, Cefazolin, Ceftriaxone, Ciprofloxacin,
Levofloxacin
IMAGING/PROCEDURES:
ERCP ___
Impression: Normal major papilla.
A mild diffuse dilation was seen at the main duct with the CBD
measuring 9 mm. No filling defects or strictures were noted on
cholangiogram. Small distal CBD stones could not be ruled out.
A biliary sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Pus drainage was noted after sphincterotomy.
A small stone was extracted successfully using an extraction
balloon catheter.
Occlusion cholangiogram was normal.
Brisk drainage of bile and contrast from the biliary tree was
noted fluorosocpically and endoscopically.
Otherwise normal ercp to third part of the duodenum
Brief Hospital Course:
___ with a history of congestive heart failure who presents with
acute cholangitis and gram negative bacteremia.
# Acute cholangitis: Presented with fever, leuckocytosis,
hypotension, postprandial RUQ pain, transaminitis, and had
evidence of cholelithiasis with gallbladder wall thickening on
US consistent with acute cholangitis. Underwent ERCP ___ w/
sphincterotomy w/ pus and stone extraction. Surgery was also
consulted and recommended conservative management. Was started
on zosyn(to treat gram negative bacteremia too) and given no PO
options, discharged on IV zosyn for two weeks ___.
# E.coli bacteremia: Likely of biliary source given. Also had
positive UA, but given negative Cx unlikely to be the source
with Ucx negative and asymptomatic. Bcx from ___ from
___ grew E.coli not sensitive to PO antibiotics. Started on
zosyn on ___. Had PICC placement on ___ and discharged on
zosyn for 14 day course. (___)
# Severe Sepsis : Admitted with fever, leukocytosis, tachycardia
and hypotension in the setting of acute cholangitis and E.coli
bacteremia. Was initially in ICU, and was fluid responsive but
had resolution of fever, leukocytosis, tachycardia and
hypotension after IVF and starting antibiotics as above.
# CHF: Unknown if systolic or dyastolic dysfunction. Mild
exacerbation in the setting of IVF resuscitation. Restarted on
home diuretics and euvolemic on discharge.
# HTN: restarted home lasix and metoprolol. Given SBP in
100-120, home losartan and imdur held on discharge
# Gout: continued home allopurinol
# GERD: Cont home omeprazole
# COPD: No acute exacerbation, continued on home medications
# Insomnia: Cont trazodone
TRANSITIONAL ISSUES:
- Patient had dependent basilar crackles and scattered wheezing
on day of discharge, but had oxygen sat of 93% lying flat
without any complaints of dyspnea, speaking in full sentences
and feeling well (no orthopnea or edema). Home diuretics
continued. Please monitor respiratory status and give lasix
accordingly.
- Zosyn through ___ line for 14-day course through ___.
Pending surveillance cultures ___ negative to date at
discharge.
- Please check CBC, electrolytes, LFTs in ___ days.
- Blood pressure ranged 100-130s with home imdur and losartan
being held which can be restarted at rehab or as outpatient.
- Home atorvastatin is being held at discharge.
- Please continue to hold home aspirin until ___
(post-sphincterotomy patients should not receive aspirin,
Plavix, NSAIDS, Coumadin for 5 days).
- Consider outpatient surgery f/u referral by PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Aspirin EC 81 mg PO DAILY
4. Spironolactone 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Enablex (darifenacin) 7.5 mg oral DAILY
7. Losartan Potassium 25 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Citalopram 10 mg PO DAILY
10. Allopurinol ___ mg PO DAILY
11. Furosemide 20 mg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Atorvastatin 10 mg PO QPM
14. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS
15. TraZODone 50 mg PO QHS
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Citalopram 10 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Furosemide 20 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Omeprazole 20 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. TraZODone 50 mg PO QHS
9. Acetaminophen 325-650 mg PO Q6H:PRN pain
do not exceed 3 gm in 24 hours
10. Piperacillin-Tazobactam 2.25 g IV Q6H GNR bacteremia,
cholecystitis
11. Enablex (darifenacin) 7.5 mg oral DAILY
12. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-Acute cholangitis
-E coli bacteremia
-SEPSIS
SECONDARY DIAGNOSIS
-HYPERTENSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms ___,
You were admitted for abdominal pain caused by an infection and
impacted stone in your gallbladder. You were transferred here
to undergo a procedure called ERCP and the stone and pus was
removed. The surgery team saw you here but did not recommend
gallbladder surgery. We recommend you follow up with your PCP
to discuss an outpatient surgery evaluation.
The infection had spread to your bloodstream so you will require
IV antibiotics through the PICC line placed in your arm for a
total of 14-days at the rehab through until ___.
Your blood pressure was well controlled without restarting imdur
and losartan which can be started at the rehab or by your PCP
with blood pressure monitoring. Your aspirin is being held
after sphincterotomy until ___ and your atorvastatin is held
which should be restarted once you are seen by your PCP.
Happy 94th birthday! Best of luck with your recovery.
Sincerely,
___ Care Team
Followup Instructions:
___
|
10414312-DS-13 | 10,414,312 | 27,237,551 | DS | 13 | 2160-06-13 00:00:00 | 2160-06-13 12:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L wrist laceration
Major Surgical or Invasive Procedure:
1. Left flexor carpi radialis, flexor digitorum
superficialis of index finger, flexor digitorum
superficialis of long finger, flexor digitorum
superficialis of ring finger, palmaris longus, as well
as flexor carpi ulnaris tendon repairs.
2. Exploration of the radial artery.
3. Neurolysis of the ulnar nerve.
4. Use of the microscope.
5. Microscopic repair of the median nerve.
6. Microscopic repair of the ulnar artery.
7. Microscopic repair of the palmar cutaneous branch of the
median nerve.
8. Open carpal tunnel release.
9. Debridement of open injury down to bone.
History of Present Illness:
___ yo male, no PMH, found today with a self-inflicted left
wrist laceration found on the side of the road with
approximately
800cc to 1L of blood in a puddle near him (garbage can top sized
pool). After drinking a fifth today, he reports that he used a
razor to slit his left wrist. No prior suicide attempts, lost
his job today.
Past Medical History:
Depression
Social History:
___
Family History:
n/c
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Musculoskeletal Upper Extremity:
Left upper extremity
* L hand median nerve sensory/motor loss
* Incision healing well with sutures
* No drainage, erythema
Bilateral lower extremities
* No calf tenderness
* ___ strength
Pertinent Results:
___ 05:08AM BLOOD WBC-11.9* RBC-3.60* Hgb-10.1* Hct-29.5*
MCV-82 MCH-27.9 MCHC-34.0 RDW-13.3 Plt ___
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
Pt was evaluated by occupational therapy and placed in a dorsal
splint. Modified ___ flexor tendon repair protocol was begun
with a passive flexion and active extension within dorsal
blocking splint.
Pt was evaluated by psychiatry and ___ was placed. He was
screened for inpatient psych.
Otherwise, pain was controlled with oral pain medications. The
patient received aspirin 325mg daily. Patient was voiding
independently. The surgical dressing was changed on POD#2 and
the surgical incision was found to be clean and intact without
erythema or abnormal drainage. Labs were checked throughout the
hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs.
Mr. ___ is medically cleared for discharge to inpatient
psych. He will follow-up on ___ in Hand Clinic.
Medications on Admission:
Prozac
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a ___ as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
4. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) for 4 weeks.
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Laceration to the left volar wrist
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting three
(3) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Stitches that need to be removed will be
taken out at first follow up appointment after your surgery.
7. Please call Dr. ___ office to schedule or confirm your
follow-up appointment in one (1) week.
8. ANTICOAGULATION: Please continue your aspirin for four (4)
weeks to help prevent thrombosis of repaired artery.
9. ACTIVITY: Continue to wear hand splint at ALL times. You will
begin an outpatient occupational therapy program as directed. No
active flexion of digits.
Physical Therapy:
Dorsal blocking splint at all times; flexor tendon repair
protocol with passive flexion and active extension within
splint.
Treatments Frequency:
Please keep your wounds clean. Dry dressings as needed. You may
shower starting three (3) days after surgery, but no tub baths
or swimming for at least four (4) weeks.
Followup Instructions:
___
|
10414481-DS-13 | 10,414,481 | 27,005,091 | DS | 13 | 2188-05-17 00:00:00 | 2188-05-17 08:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___ Diagnostic cerebral angiogram
History of Present Illness:
___ pmh HTN p/w SAH from ___. Symptoms of throbbing in
occiput while lying down in bed and then severe headache and
"seeing double". Visual symptoms resolved by themselves. Started
at ___ on day of admission. Not on blood thinners. No recent
cocaine use. Denies N/V. No sensory problems. Currently HA ___
("was 200 earlier"). CT from OSH: ___ in prepontine and
interpeduncle cisterns - susp. of BA aneurysm.
Past Medical History:
HTN
Social History:
___
Family History:
No family history of aneurysms, brain hemorrhage, sudden death.
Physical Exam:
PHYSICAL EXAM:
___ and ___: 2 Fisher:3 GCS-15 E: 4 V:5 Motor:6
T:97.8 HR:76 BP:140/107 RR:18 SAT:97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: normal Pupils: PERRLA EOMs: normal
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 1
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger
Handedness: Right
ON DISCHARGE:
Patient was not examined prior to discharge as he left against
medical advice.
The most recent exam prior to discharge on ___:
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Pertinent Results:
___ CTA HEAD/NECK W & W/O CONTRAST
IMPRESSION:
1. No intracranial aneurysms. However, the study is limited by
poor vascular opacification. Sensitivity for detecting
aneurysms will be reduced as compared to and optimal study.
2. Mild narrowing of the distal basilar artery, which may
represent vasospasm.
3. Patent vasculature in the neck with no evidence of internal
carotid artery stenosis by NASCET criteria.
4. Unchanged subarachnoid hemorrhage. No new hemorrhages.
___ DIAGNOSITC ANGIOGRAM
Right common carotid artery: The right carotid bifurcation is
well visualized without significant arteriosclerotic disease of
stenosis. The right anterior intracranial circulation is
unremarkable. No evidence of vascular lesion or vasospasm.
Left common carotid artery: The left carotid bifurcation is well
visualized without significant arteriosclerotic disease of
stenosis. The left anterior intracranial circulation is
unremarkable. No evidence of vascular lesion or vasospasm.
Left vertebral artery: The post intracranial circulation is
unremarkable. No evidence of vascular lesion or vasospasm.
Right vertebral artery: The post intracranial circulation is
unremarkable. No evidence of vascular lesion or vasospasm.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Grossly stable subarachnoid hemorrhage with interpeduncular
cistern and
prepontine cistern.
2. No definite new or enlarging intracranial hemorrhage
identified.
3. No evidence of large territorial acute infarction.
4. Please note MRI of the brain is more sensitive for the
detection of acute
infarct.
___ CT HEAD W/O CONTRAST
IMPRESSION:
Evolution of subarachnoid hemorrhage since ___. No
new hemorrhage.
Brief Hospital Course:
On ___ Mr. ___ was transferred from ___ with
pre-pontine SAH. CTA was negative for aneurysm. He was admitted
to the neuro ICU and a diagnostic cerebral angiogram was
performed. Angiogram negative for vascular malformation or
aneurysm. He tolerated the procedure well and right groin was
angiosealed. He was transferred back to SICU for continued close
neurological monitoring.
On ___, neuro exam stable however complaining of worsening
headache and diaphoresis, concerning for withdrawal, patient was
placed on CIWA. Started on a Medrol dose pak for headache. CT
Head was completed due to complaints of worsening headache and
was stable.
On ___, worsening headache, repeat head CT stable. To maintain
euvolemia, received multiple boluses and restarted IVF that were
stopped.
On ___, neurologically stable. Sodium ___ is 131, patient
started on salt tablets and will monitor closely. Will continue
with ICU level of care.
On ___, neurologically stable, denies headache during morning
rounds. Hypertonic saline maintains at 20cc/hr, sodium tablets
increased to 2grams TID. Continues to require nicardipine gtt,
PO agent added to regimen to be able to wean nicardipine gtt.
On ___, the patient remained neurologically stable. His sodium
tablets were increased to 3grams TID and hypertonic saline
increased to 30cc/hr due to continued downtrending serum sodium,
which stabilized after increase. The patient's blood pressure
parameters were liberalized to SBP <160 and he remained off of
nicardipine.
On ___, the patient was discharged against medical advice. He
was instructed to follow up with his PCP immediately after
discharge to follow up on care initiated during his
hospitalization and to return to the nearest Emergency
Department or call ___ with any worsening of symptoms.
Medications on Admission:
NONE
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Captopril 6.25 mg PO TID
RX *captopril 12.5 mg 0.5 (One half) tablet(s) by mouth three
times daily Disp #*45 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Sodium Chloride 3 gm PO TID
THE PATIENT WAS ADVISED TO FOLLOW UP WITH HIS PCP TO CONTINUE
MEDICATION INITIATED DURING HIS HOSPITAL STAY AS HE LEFT AGAINST
MEDICAL ADVICE.
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
DISCHARGED AGAINST MEDICAL ADVICE
Discharge Instructions:
****DISCHARGED AGAINST MEDICAL ADVICE****
You were hospitalized for subarachnoid hemorrhage.
You are being discharged against medical advice. The
neurosurgical team strongly advises remaining in the hospital
for close neurological monitoring and further testing. You are
also advised to return to the nearest Emergency Department or
call ___ if you experience any worsening symptoms or any of the
Danger Signs below.
You were treated for high blood pressure and low sodium levels
during your hospitalization. Please follow-up with your PCP
after discharge to monitor this and manage your medications.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10414622-DS-10 | 10,414,622 | 29,875,260 | DS | 10 | 2168-11-05 00:00:00 | 2168-11-06 07:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ female with PMH of asthma, and depression,
who presents with dyspnea with worsened cough; clear sputum.
She reports several episodes of sinus congestion, rhinorrhea,
productive cough over the past 3 weeks. These have been waxing
and waning in nature and recurred over this weekend as well as
shortness of breath with exertion and at rest. She also reports
cough and sensation of chest tightness. Sick contacts include
family daughter and granddaughter with cold symptoms.
She does have a history of mild intermittent asthma in the past
but has had more frequent flares in the last year. No prior
admissions for exacerbation.
She denies fevers but reports chills. Intermittent rhinorrhea
and nasal congestion. No sorethroat. No myalgias or arthralgias.
No nausea, vomiting, diarrhea, abdominal pain, dysuria or
urinary frequency.
In the ED,
-initial vital signs were: 0 98.5 126 122/83 20 96% RA
- Exam was notable for: Peak flow 150, improved to 200 after
nebs, and prednisone
- Labs with negative flu PCR, WBC of 11.3, normal chem 10,
negative troponins
-CXR with hyperinflation and no infiltrate
-EKG ST 117, NA, NI, inferior and lateral submm STD , that are
new from ___ ___ records
- The patient was given:
IVF 1000 mL NS 1000 mL x 2
IV Ketorolac 30 mg x 1
PO Acetaminophen 1000 mg x 1
IH Albuterol 0.083% Neb Soln 1 NEB x 3
IH Ipratropium Bromide Neb 1 NEB x 3
PO PredniSONE 60 mg x 1
PO Aspirin 324 mg x 1
Vitals prior to transfer were: 8 98.5 106 100/54 16 97% RA
Upon arrival to the floor, she reports significant improvement
in symptoms. Chest tightness not completely resolved but barely
noticeable. No wheezing.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, fevers, sweats, weight loss, abdominal pain,
nausea, vomiting, diarrhea, constipation, hematochezia, dysuria,
rash, paresthesias, and weakness.
Past Medical History:
Mild intermittent asthma
Anxiety
Tobacco dependence
Sleep apnea, obstructive: uses CPAP at night
Osteopenia
Restless legs syndrome-not on meds
Colonic polyp
CIN I
H/O HSV
Social History:
___
Family History:
Brother ___
Daughter ___
Father heart disorder
___ Grandmother ___ heart disorder
Mother ___
___ Aunt Cancer - ___
Paternal Grandmother Cancer
Physical ___:
ADMISSION PHYSICAL EXAM:
VITALS: 98.3 110/71 hr 93 rr18 97%RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: no wheezing on auscultation bilaterally with
appreciable air movement.
ABDOMEN: soft, non-tender, non-distended, no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal
DISCHARGE PHYSICCAL EXAM:
VITALS: 98.1 110/59 102 18 96RA
Tele: ___, SR, 9 sec run of RBBB, occ desat ___
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: no wheezing on auscultation bilaterally but with
mildly decreased air movement
ABDOMEN: soft, non-tender, non-distended, no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal
Pertinent Results:
LABORATORY STUDIES ON ADMISSION
======================================================
___ 05:40PM BLOOD WBC-11.3* RBC-4.24 Hgb-12.6 Hct-37.6
MCV-89 MCH-29.7 MCHC-33.5 RDW-12.9 RDWSD-41.4 Plt ___
___ 05:40PM BLOOD Neuts-89.3* Lymphs-5.0* Monos-3.9*
Eos-1.1 Baso-0.2 Im ___ AbsNeut-10.09* AbsLymp-0.57*
AbsMono-0.44 AbsEos-0.12 AbsBaso-0.02
___ 05:40PM BLOOD ___ PTT-26.0 ___
___ 05:40PM BLOOD Glucose-130* UreaN-15 Creat-0.8 Na-138
K-3.9 Cl-102 HCO3-24 AnGap-16
___ 05:40PM BLOOD cTropnT-<0.01
___ 05:40PM BLOOD Calcium-9.9 Phos-3.3 Mg-1.6
___ 09:40PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:40PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
___ 09:40PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-4
___ 09:40PM URINE Mucous-MANY
___ 05:44PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICROBIOLOGY
======================================================
URINE CULTURE: pending
IMAGING
======================================================
PA & LAT CHEST XRAY ___
IMPRESSION:
Hyperinflated lungs without acute cardiopulmonary process.
LABORATORY STUDIES ON DISCHARGE
======================================================
___ 06:20AM BLOOD WBC-5.7 RBC-3.49* Hgb-10.3* Hct-31.9*
MCV-91 MCH-29.5 MCHC-32.3 RDW-13.1 RDWSD-44.2 Plt ___
___ 06:20AM BLOOD Neuts-89.8* Lymphs-7.8* Monos-1.6*
Eos-0.4* Baso-0.0 Im ___ AbsNeut-5.09 AbsLymp-0.44*
AbsMono-0.09* AbsEos-0.02* AbsBaso-0.00*
___ 06:20AM BLOOD Glucose-169* UreaN-14 Creat-0.6 Na-140
K-3.8 Cl-106 HCO3-25 AnGap-13
Brief Hospital Course:
Ms. ___ is a ___ year old woman with mild intermittent asthma
who was admitted with dyspnea and cough, and found to have an
asthma exacerbation.
#Asthma Exacerbation:
Pt presented with an asthma exacerbation likely precipitated by
recent upper respiratory infection. On admission, pt noted to
have a peak flow of 150 (33% predicted) that improved to 200
(44% predicted) after nebulizers. No evidence of infiltrates on
CXR, and negative flu swab. Pt was managed with nebulizers and
prednisone with significant improvement. On discharge, peak flow
350 (76% predicted). Pt discharged with albuterol inhaler and a
plan to complete a 5-day course of prednisone (last day
___.
# Chest discomfort:
On admission, pt reported intermittent chest discomfort that was
non-exertional and not relieved by rest. Initial EKG with
inferior submm STD that resolved on repeat EKG with normal
rates. Troponin negative. Likely secondary to asthma
exacerbation with low suspicion for ACS.
# Anxiety:
Continued home citalopram
# Sleep apnea:
Continued home CPAP
TRANSITIONAL ISSUES
==================================
1. Consider outpatient PFTs
2. Consider outpatient stress test.
3. Pt should have ongoing smoking cessation counseling. Pt
discharged with nicotine patches but would like to discuss
Chantix and Bupropion with her PCP.
4. Pt should complete a 5-day course of prednisone (last day
___
# CONTACT: Boyfriend, ___ ___
# CODE STATUS: full code, confirmed with patient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Acyclovir 400 mg PO Q8H
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 prn anaphylaxis
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 prn anaphylaxis
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 PUFF INH Q4H:PRN
Disp #*2 Inhaler Refills:*0
5. Acyclovir 400 mg PO Q8H
6. PredniSONE 30 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg 3 tablet(s) by mouth DAILY Disp #*9 Tablet
Refills:*0
7. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour Apply 1 patch Daily Disp #*14 Patch
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
for an exacerbation of your asthma. You were treated with
inhalers and steroids. It is very important for you to continue
taking your medications as prescribed. It is also very
important for you to stop smoking.
Please see below for your upcoming appointments.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10414738-DS-9 | 10,414,738 | 26,922,052 | DS | 9 | 2165-08-25 00:00:00 | 2165-08-25 15:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
acute onset L flank pain
Major Surgical or Invasive Procedure:
___: Cystoscopy, LEFT ureteroscopy and left ureteral stent
placement
History of Present Illness:
___ with h/p nephrolithiasis presenting to the ED with acute
onset L flank pain. Describes the pain as sharp and localized to
L flank with radiation to groin. Denies fever of chills.
Endorses hematuria. Denies frequency, urgency, or change in
bowel habits. Found to have left 5mm stone.
Past Medical History:
Nephrolithiasis
Social History:
___
Family History:
non-contributory
Physical Exam:
wdwn male, nad, avss
abdomen benign, soft, nt/nd
extremities w/out edema, pitting.
Pertinent Results:
___ 06:25AM BLOOD WBC-9.2 RBC-4.39* Hgb-13.4* Hct-39.1*
MCV-89 MCH-30.6 MCHC-34.4 RDW-12.0 Plt ___
___ 06:25AM BLOOD Glucose-113* UreaN-16 Creat-1.0 Na-139
K-3.8 Cl-106 HCO3-21* AnGap-16
Brief Hospital Course:
Mr. ___ was admitted to Dr. ___ service
from the ED for overnight observation, pain control, and IV
fluids and IV antibiotics. He was monitored for fever, nausea
and vomiting and prepared for ureteral stent placement on
hospital day one. He underwent LEFT uretersopy and ureteral
stent placement. No concerning intra-operative events occurred;
please see dictated operative note for full details. The
patient received ___ antibiotic prophylaxis. At the
end of the procedure the patient was extubated and transported
to the PACU for further recovery before being transferred to the
floor. He was transferred from the PACU in stable condition to
the general surgical floor. On POD1 he had his Foley removed and
voided without difficulty. At discharge Mr. ___ had
pain that was well controlled with oral pain medications, he
was tolerating a regular diet and he was ambulating without
assistance and voiding without difficulty. He was given explicit
instructions to follow-up with Dr. ___ definitive stone
management and ureteral stent removal/exchange.
Medications on Admission:
NONE
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for burning urination for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
NEPHROLITHIASIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge instructions with or without URETERAL STENT
PLACEMENT:
You have an indwelling ureteral stent that MUST be removed
and/or exchanged in the next few weeks time. Please follow-up as
advised.
You may experience some pain associated with spasm of your
ureter especially while there is an INDWELLING URETERAL STENT.
This is normal
-Resume all of your pre-admission/ home medications, unless
otherwise noted. Please avoid Aspirin unless otherwise advised.
-No vigorous physical activity for 2 weeks.
-Expect to see occasional blood in your urine and to experience
urgency and frequency over the next month.
-You may have already passed your kidney stones OR they may
still be in the process of passing.
-You may experience some pain associated with spasm of your
ureter. This is normal. Take IBUPROFEN as directed and take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Make sure you drink plenty of fluids to help keep yourself
hydrated and facilitate passage of stone fragments.
-You may shower and bathe normally.
-Do not drive or drink alcohol while taking narcotics or operate
dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative
-If you have fevers > 101.5 F, vomiting, severe abdominal pain,
or inability to urinate, call your doctor or go to the nearest
emergency room.
Call your urologists office for follow-up AND if you have any
questions.
Followup Instructions:
___
|
10415221-DS-8 | 10,415,221 | 22,303,929 | DS | 8 | 2199-07-23 00:00:00 | 2199-07-23 15:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
shortness of breath and cough x2 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ only with hx of asthma (no PFTs in ___
records), CAD s/p DES to RCA ___, depression, IDDM2,
hypertension, GERD, and osteoarthritis presenting with
productive cough and shortness of breath x 2 days. History is
obtained with assistance of pt's daughter, ___, who speaks
___ fluently. Pt reports that her symptoms began 2 days
prior to presentation, when she developed cough productive of
white/yellow sputum, wheezing, and difficulty with exhalation.
Pt reports that she used her inhaler - she believes it was
albuterol - with minimal relief. On the day of presentation, she
was lying in bed at about 11 am, and noted dyspnea when she got
out of bed to go to the bathroom. She had noted chills and
nonexertional, nonradiating chest tightness earlier that
morning. Upon getting out of bed, she had cough productive of
yellow phlegm mixed with blood, at which time she was brought to
the ED for further evaluation.
On admission to the floor, she notes that her cough has been
accompanied by rhinorrhea; she has had mild headache which is
currently very minimal. She reports chronic reflux pain which is
improved compared to baseline, although still present. She
denies chest pain, dysuria, diarrhea, hematochezia, melena. She
endorses constipation, chronic abdominal pain as above, chronic
symmetric ___ edema. She sleeps with 2 small pillows.
Of note, she has recently suffered multiple losses in her
family, including death of her brother. She traveled to ___
approx 3 weeks prior to this presentation, with flight from
___ to ___, then change to ___. She did note marked
increase in bilateral ___ edema, which was symmetric, and without
calf pain.
In the ED:
T 98.1, HR 68, BP 168/71, RR 20, SaO2 97% RA
Prior to transfer to floor: HR 73, BP 117/48, RR 16, SaO2 96% RA
Labs notable for lactate 3.2
WBC 6.7
BCx and UCx sent
CXR: Vague right lower lobe opacity may be secondary to
vascular
engorgement in the setting of low lung volumes.
EKG without ischemic changes
Received:
Duonebs
Prednisone 20 mg
Azithromycin 250 mg
Ceftriaxone
Lorazepam 1 mg
Pantoprazole 40 mg
Ondansetron
Past Medical History:
CAD s/p DES to RCA ___
Asthma - per OMR, no PFTs available
Osteoarthritis with prior steroid joint injections
Depression on sertraline
IDDM2: last A1C 7.9 on ___
Hyperlipidemia (fasting LDL 90 on ___
GERD s/p EGD ___ with chronic nonspecific inflammation,
otherwise unremarkable
Hypertension
Social History:
___
Family History:
Father with CAD
brother leukemia
Physical ___:
VS:
T98.7, HR 89, BP 155/67, RR 18, SaO2 94%RA
Gen: Obese, blunted affect, resting comfortably in bed, NAD
HEENT: PERRL, EOMI, ___ present
CV: RRR, normal S1/S2, ___ systolic murmur heard at RUSB without
radiation to carotid or apex
Pulm: Diffuse expiratory wheeze, no rales or crackles
Abd: obese, soft, NT, ND
Ext: symmetric trace pitting edema b/l ___, no clubbing or
cyanosis, no calf tenderness to palpation, negative ___ sign
bilaterally
Neuro: grossly intact, moves all extremities
Psych: blunted affect, appears sad
Pertinent Results:
___ 03:40PM URINE ___ SP ___
___ 03:40PM URINE ___
___
___
___ 02:38PM ___
___ 02:30PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 02:30PM cTropnT-<0.01
___ 02:30PM ___
___
___ 02:30PM ___
___
___ 02:30PM PLT ___
EKG: NSR at 68, leftward axis, normal intervals, TW flattening
in III and aVF, no ST segment changes
Prior data:
TTE ___
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Doppler parameters are indeterminate for
left ventricular diastolic function. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Preserved global and regional biventricular systolic
function. Mild mitral regurgitation with mildly thickened
leaflets.
Compared with the prior study (images reviewed) of ___,
diastolic function indices are indeterminate on the current
study. The other findings are similar.
Left heart catheterization ___
COMMENTS: 1. Coronary angiography in this right dominant system
revealed
one vessel coronary artery disease. The ___ had no
___ disease. The LAD had mild diffuse
disease. The
LCx had no angiographically apparent disease. The RCA had a mid
90%
stenosis with slightly decreased flow.
2. Limited resting hemodynamics revealed an elevated left sided
filling
pressure with LVEDP of 37 mmHg. There was normal systemic
arterial
pressure with SBP of 131 mmHg and DBP of 51 mmHg.
3. Left ventriculography was deferred.
3. Successful PTCA and stenting of the mid RCA with a Cypher
(2.5x28mm) drug eluting stent postdilated with a 2.75mm balloon.
Final
angiography demonstrated no angiographically apparent
dissection, no
residual stenosis and TIMI III flow throughout the vessel (See
___
comments).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate left ventricular diastolic dysfunction.
3. Successful PTCA and stenting of the mid RCA with a Cypher
(2.5x28mm)
drug eluting stent postdilated with a 2.75mm balloon.
Brief Hospital Course:
___ year old female with history of CAD, diabetes, depression,
and
asthma, presenting with 2 day history of productive cough,
dyspnea, wheezing consistent with asthma exacerbation.
ACTIVE ISSUES
-------------
# Asthma exacerbation: She carries a diagnosis of asthma (no PFT
in ___ system) and takes albuterol and symbicort for home
regimen. She presented with cough, dyspnea and wheezing and was
found to have expiratory wheeze on exam consistent with asthma
exacerbation. She does have known CAD, but ECG was without
ischemic changes, and troponin negative x 2. She was placed on
standing Duonebs, prednisone 40 mg PO daily, azithromycin for a
five day course with improvement in symptoms. She should have
formal PFTs upon resolution of this episode.
INACTIVE ISSUES
---------------
# Diabetes: On Humalog ___ at home, last hemoglobin A1C 7.9.
She was continued on her home fixed dose insulin, as well as
Humalog sliding scale. Metformin was held during her admission,
but will be restarted on discharge.
# Hypertension: hypertensive on presentation, improved in ED
with lorazepam. Upon arrival to the floor, she was restarted
on her home medications.
# Coronary artery disease: No evidence of cardiac ischemia at
this time. Given known
history, biomarkers were trended. Aspirin dose was decreased
from 325 mg daily to 81 mg daily given increased risk of
bleeding without evidence of benefit this far out from PCI.
# Hyperlipidemia: patient was continued on her home
atorvastatin.
# GERD: Improved reflux symptoms compared to baseline. Patient
was continued on her home omeprazole.
# Depression: Followed closely by PCP for depression. Patient
was continued on her home sertraline and benzodiazepine.
TRANSITIONS OF CARE
-------------------
[ ] follow up with her PCP ___ - based on symptoms and exam
may consider longer steroid course/taper
[ ] recommend PFTs as outpatient after resolution of acute
illness
# Code status: Full code, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Atorvastatin 80 mg PO DAILY
4. Symbicort ___ mcg/actuation
inhalation BID
5. ClonazePAM 1 mg PO QHS:PRN anxiety, insomnia
6. Furosemide 20 mg PO DAILY
7. Humalog ___ 50 Units Breakfast
Humalog ___ 20 Units Bedtime
8. Losartan Potassium 25 mg PO DAILY
9. MetFORMIN (Glucophage) 850 mg PO BID
10. Omeprazole 40 mg PO DAILY
11. Sertraline 50 mg PO QAM
12. Aspirin 325 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Humalog ___ 50 Units Breakfast
Humalog ___ 20 Units Bedtime
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Sertraline 50 mg PO QAM
8. ClonazePAM 1 mg PO QHS:PRN anxiety, insomnia
9. MetFORMIN (Glucophage) 850 mg PO BID
10. Symbicort ___ mcg/actuation
inhalation BID
11. Azithromycin 250 mg PO Q24H Duration: 2 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath
14. Losartan Potassium 25 mg PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
16. PredniSONE 40 mg PO QAM Duration: 3 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
17. Ipratropium Bromide Neb 1 NEB IH Q6H
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 vial INH Q6 Disp
#*30 Vial Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring you at the ___. You came for further
evaluation of shortness of breath. You were determined to have
an asthma exacerbation. You improved with nebulizer treatments,
antibiotics and steroids. It is important that you continue to
take your medications as prescribed.
- You should take the albuterol nebulizer every six hours.
- You should take the ipratropium nebulizer every six hours
(prescription given)
- You should take azithromycin once daily for the next two days
(prescription given)
- You should take prednisone once daily for the next three days
(prescription given)
-You can take the albuterol nebulizer every six hours as needed
for wheezing or shortness of breath
You will follow up with your appointments as scheduled - you
will see your primary care physician ___.
Followup Instructions:
___
|
10415625-DS-10 | 10,415,625 | 20,191,935 | DS | 10 | 2121-07-25 00:00:00 | 2121-07-25 14:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bilateral ___ pain and discharge
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of remote house fire leading to diffuse, severe
(?70% BSA) burns requiring reconstructive surgeries c/b multiple
wound infections, anoxic brain injury and seizure d/o ___ same
house fire presenting with malodorous purulent discharge from
chronic ___ wounds, L>R. History is limited by apparently
baseline cognitive impairment. Per pt, he has been in multiple
EDs over the past year or so, reports using multiple rounds of
antibiotics without resolution of infections. He states that he
did receive at least one course of abx via PICC line, with
?resolution of infection, but notes that he never completed a
full course of IV abx for various reasons (jail, etc). He
endorses pain and pruritis at bilateral LEs, with associated
drainage. He denies fevers, endorses chills, and endorses
drenching night sweats in the 1 month prior to presentation.
Of note, pt reports that he has used IV heroin until 6 months
prior to admission, while also stating his short term memory is
quite impaired, and that some of his details may be inaccurate.
He believes that he has hepatitis C infection. He states that
his sister aware of his drug use, although in discussion with
his sister by telephone, she is unaware of a history of IVDA.
She states that it is possible he has previously used IVDA. She
does confirm that he was in jail for three times in ___:
___, and again early ___
(released 3 weeks prior to presentation). She in uncertain of
the reason for incarceration. She notes that he previously
stayed with her 8 months prior to presentation, but subsequently
he moved in with his mother, and has intermittently been
undomiciled.
Since the patient has been staying with her, she is certain that
he has been taking Keppra reliably. She watches him take it
twice daily. She plans to visit him in to the hospital on
___.
In the ___ ED:
VS 98.9, 111->73, 124/68, 100% RA
On exam, LLE with purulent drainage visible below border of
dressing, malodorous, chronic erythema in areas of skin grafting
Labs notable for Cr 0.6, WBC 6.8, CRP 23.0
BCx sent
Evaluated by plastic surgery service, recommended wound care to
BLE with Adaptec, moist gauze, Kerlex, and ACE wrap. Admit to
medicine for IV abx, recommend vanc/zosyn. Plastic surgery
service will follow and assist with wound care.
Received ibuprofen 600 mg PO x1, Keppra 1000 mg PO x1 (home
med), Zosyn 4.5 g IV x1, vancomycin 1000 mg IV x1
On arrival to the floor, he describes pain ___, stabbing,
pruritic in bilateral LEs.
ROS: All else negative
Past Medical History:
- Diffuse burns: per PCP ___ ___, house fire in ___
___, in a coma for 2 months, with course complicated by
severe burns requiring multiple skin grafts, muscle grafts,
orthopedic surgeries, osteomyelitis of LLE, contractures of L
hand and forearm, chronic pain
- Seizure disorder: ___ anoxic brain injury related to house
fire, on keppra
- HCV infection - reported by patient
Social History:
___
Family History:
Per OMR:
Mother with DM2 and htn, father died at age ___ with chronic
bronchitis, pulmonary disease, smoker
Physical Exam:
Admission PE:
VS 97.8 PO 105 / 57 66 18 99 RA
Gen: Very pleasant male, alert, interactive, NAD
HEENT: PERRL, EOMI, clear oropharynx, anicteric sclera
Neck: supple, no cervical or supraclavicular adenopathy
CV: RRR, no m/r/g
Lungs: CTAB, no wheeze or rhonchi
Abd: post surgical changes (s/p multiple
grafts/reconstructions), soft, nontender, nondistended, no
rebound or guarding, normoactive bowel sounds, no hepatomegaly,
no fluid wave or bulging flanks, no palmar erythema
GU: No foley
Ext: Dressings in place over bilateral LEs removed. BLE s/p
burns with diffuse soft tissue reconstruction distal to
bilateral knees, with atrophy of LLE>RLE. Diffuse and patchy
areas of erythema and hyperpigmentation, with multiple areas of
ulceration draining serous fluid. Deepest ulceration is LLE,
medial aspect, superior to medial malleolus, measuring 3x3 cm,
without necrosis. 2+ DPs bilaterally. Contractures of RUE
digits.
Neuro: grossly intact
Psych: Alert, interactive, very pleasant, animated in
conversation, describes his own significant short term memory
impairment
Discharge PE:
VS: 97.7 109 / 61 56 18 100 RA
Gen: NAD, pleasant, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM, OP clear
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: Soft, NT, ND +BS, well-healed mid-line scar
Ext: BLE s/p burns with diffuse soft tissue reconstruction
distal
to bilateral knees, with atrophy of LLE>RLE. Diffuse and patchy
areas of erythema and hyperpigmentation, with multiple areas of
superficial ulceration draining serous fluid. No purulent
drainage, bogginess or severe tenderness.
Neuro: CN II-XII intact, ___ strength throughout, poor short and
long term memory
Psych: normal affect
Pertinent Results:
___ 01:29PM LACTATE-1.1
___ 01:10PM GLUCOSE-87 UREA N-15 CREAT-0.6 SODIUM-137
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-28 ANION GAP-12
___ 01:10PM estGFR-Using this
___ 01:10PM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-1.8
___ 01:10PM CRP-23.0*
___ 01:10PM WBC-6.8 RBC-4.45* HGB-12.0* HCT-38.3* MCV-86
MCH-27.0 MCHC-31.3* RDW-15.0 RDWSD-47.6*
___ 01:10PM NEUTS-43.1 ___ MONOS-12.8 EOS-7.5*
BASOS-0.4 IM ___ AbsNeut-2.93 AbsLymp-2.44 AbsMono-0.87*
AbsEos-0.51 AbsBaso-0.03
___ 01:10PM PLT COUNT-257#
___ B/L tib/fib X-rays:
IMPRESSION:
Right lower leg : No acute fractures or dislocations are seen.
There are
calcifications and irregularity involving the syndesmosis
between the distal tibia and fibula. In addition, there is
cortical irregularity and periostitis along the fibular shaft.
These findings can be consistent with reported history of prior
osteomyelitis. Acute on chronic process would be difficult to
exclude and if there is high concern, MRI could be performed.
Single surgical clip is seen within the medial soft tissues of
the knee. There is spurring at the tibial tubercle.
Calcifications are seen the region of the Achilles tendon there
is thickening of the Achilles tendon. There are moderate
degenerative changes of the talonavicular joint.
Left lower leg: Numerous surgical clips are seen in the distal
leg. There is a large cortical defect and cortical regularity
in the distal tibia. In addition, there is periostitis and
irregularity of the fibular shaft. These findings can be
compatible with reported history of prior chronic osteomyelitis.
Acute on chronic osteomyelitis would be difficult to exclude and
if there is high clinical concern, MRI could be performed.
There is demineralization. There are degenerative changes with
narrowing of the tibiotalar and talonavicular joints.There are
no erosions. There is spurring about the medial tibial plateau.
Brief Hospital Course:
___ with hx of remote house fire leading to diffuse, severe
(?70% BSA) burns requiring reconstructive surgeries c/b multiple
wound infections, anoxic brain injury and seizure d/o ___ same
house fire presenting with lower extremity pain and increased
drainage.
# Chronic lower extremity wounds
# Possible cellulitis
No fevers or leukocytosis, ESR and CRP minimally elevated.
Reviewed records from ___ and he has had similar presentations
to there recurrently over the last year treated with wound care
and short courses of antibiotics. Unclear if there is active
infection or this is all poor wound healing due to
non-compliance with wound care. Started on Vanc/Zosyn in ED per
plastic surgery recs. Plain films cannot exclude acute on
chronic osteomyelitis but clinically suspicion is low for deep
tissue/bone infection. IV antibiotics were discontinued as
there were no signs of systemic infection and his wound drainage
significantly improved, he was transitioned to PO Clindamycin to
complete a total 10 day course.
- Follow-up with plastic surgery and wound clinic, set up with
home ___ to assist with wound care
- Continue PO clindamycin to complete a total 10 day course
- After appropriate wound care and treatment if he has
persistent non-healing ulcers plastic surgery recommending
referral to dermatology for biopsy of an ulcer
- Pain control with Tylenol, ibuprofen
# Seizure disorder: Unclear if these are withdrawal seizures or
a primary seizure disorder, no documented epileptiform activity
by EEG on prior evaluation at ___. Maintained on keppra 1000
mg BID per patient and his sister. He has not had any
documented seizures at ___ or here and unclear if he has been
compliant with Keppra.
- Continue home keppra
# Chronic pain: PMP reviewed, printed, and placed in chart. No
concerning patterns of prescriptions but per ___ records has
multiple hospitalization with both heroin and prescription
opioid overdoses and has injected prescription opioids in the
past.
-Avoiding opioids.
# Hx of IVDA: Has history of IVDU as recently as a few months
prior. Hepatitis C antibody positive with high viral load. HIV
negative. Hepatitits B core antibody positive, surface
anti-body and antigen negative indicating likely window period
infection. Social work was consulted.
# HCV
# HBV
No evidence of decompensated liver disease, LFTs normal.
- Follow-up hepatitis B viral load which is currently pending
- Outpatient hepatology follow up to discuss treatment
#Social: Has been intermittently living with mother, girlfriend
and sister, occasionally homeless and recently was incarcerated.
Met with patient, his sister and brother in law. Due to his
chronic poor memory and drug abuse he has not been getting
appropriate medical care and has been missing most of his
outpatient appointments. Plan for him to live with his sister
(address ___, Unit 4, ___ who plans on
bringing him to his medical appointments and assist with giving
him his medications and wound care.
# FEN: Regular diet
# PPx: Heparin sc
# CONTACT: Sister ___ (___),
___ or sister's husband ___ (___)
# CODE STATUS: FULL CODE - presumed
#Dispo: home with services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 1000 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Do not exceed 3 grams of Tylenol in a day.
2. Clindamycin 600 mg PO Q6H
RX *clindamycin HCl 300 mg 2 capsule(s) by mouth four times a
day Disp #*56 Capsule Refills:*0
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
4. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chronic non-healing lower extremity wounds with possible
super-infection
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent but poor short term memory
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted for worsening pain and drainage from your leg
wounds. You were seen by the plastic surgery, infectious
disease and wound care teams. You were put on IV antibiotics
with improvement and are being discharged with antibiotics by
mouth. Please follow-up with your primary care physician,
plastic surgery and wound care as scheduled. We also recommend
that you follow-up with the liver doctors (___) to
discuss treatment of your hepatitis C.
Followup Instructions:
___
|
10415772-DS-14 | 10,415,772 | 20,648,185 | DS | 14 | 2180-11-01 00:00:00 | 2180-11-01 16:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Alcohol intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ ___ year-old woman with a history of COPD 4L home O2
requirement at night presenting with acute alcohol intoxication.
She was brought in by EMS for being out on the streets and was
having difficulty ambulating. She states that she did not to
leave home with her oxygen because she wanted to go out "to get
some booze". She states that she had about half a pint of vodka
today. Of note, she has a recent medical ICU admission for
hypoxemia. She denies any evidence of trauma and has no
complaints, denies any head, neck, back pain.
On arrival to the ED, initial vitals were 99.8 117 126/61 89%
RA. Labs were notable for WBC 10.6 71% PMNs, HCT 31%, Plts 469,
Cr 0.4 Osms 348, Lactate 4.9 -> 3.5. UA WNL. He received valium,
thiamine, folic acid and multivitamin. Vitals on transfer were
98.5 108 141/90 21 96%.
On arrival to the general medical floor, the patient appears
comfortable and is without additional complaints.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
Alcohol Dependence
COPD
Osteoporosis
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission:
VS - 97.8 116 18 157/85 100% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD
CV: Sinus tachycardia, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Diminished breath sounds bilaterally, scattered end
expiratory wheezes, no rhonchi or crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, scattered eccymosis
GU: foley
Ext: warm, well perfused, 2+ pulses, onychomycosis
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait and coordination not tested
Discharge:
VS - 97.9 110 20 158/100 95% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD
CV: RR, tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Diminished breath sounds bilaterally, no wheezes, rhonchi
or crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, scattered eccymosis
GU: foley
Ext: warm, well perfused, 2+ pulses, onychomycosis
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait and coordination not tested
Pertinent Results:
Admission:
___ 12:15PM BLOOD WBC-10.6 RBC-3.78* Hgb-9.1* Hct-31.1*
MCV-82 MCH-24.2* MCHC-29.4* RDW-18.8* Plt ___
___ 12:15PM BLOOD Neuts-71.9* ___ Monos-6.1 Eos-1.0
Baso-1.2
___ 12:15PM BLOOD Glucose-99 UreaN-7 Creat-0.4 Na-145 K-3.6
Cl-102 HCO3-32 AnGap-15
___ 12:48PM BLOOD ___ pO2-93 pCO2-60* pH-7.33*
calTCO2-33* Base XS-3
___ 12:31PM BLOOD Lactate-4.9*
Discharge:
___ 07:10AM BLOOD WBC-7.9 RBC-3.61* Hgb-8.6* Hct-29.7*
MCV-82 MCH-23.7* MCHC-28.8* RDW-18.8* Plt ___
___ 07:10AM BLOOD Glucose-102* UreaN-4* Creat-0.5 Na-144
K-4.2 Cl-104 HCO3-29 AnGap-15
___ 07:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.7
___ 04:39PM BLOOD ___ pO2-52* pCO2-59* pH-7.31*
calTCO2-31* Base XS-0 Intubat-NOT INTUBA
___ 04:39PM BLOOD Lactate-3.5*
Chest Xray:
Mild pulmonary congestion and cardiomegaly. No evidence of
pneumonia.
Brief Hospital Course:
___ year-old woman with COPD on home O2 presenting with alcohol
intoxication.
Active Issues:
# Alcohol Intoxication: Patient has a history of alcohol
dependence with withdrawal symptoms. She required high oral
doses of diazepam durring a prior MICU admission. During her
recent admission she did not express interest in a
detoxification program. On present admission, she was monitored
on CIWA scale and showed no signs of withdrawal other than sinus
tachycardia to 120s which is consistent with her prior hospital
visits. She was continued on thiamine, folate, multivitamin. Her
lactate trended down after IV fluids. Patient was strongly
encouraged to decrease her alcohol intake.
# Sinus tachycardia: Patient was noted to be tachycardic on
previous admissions. She was tachy to 120s on prior
hospitalization, work up negative for PE. ___ be related to
alchol withdrawal or anxiety. No pain or signs of infection.
# COPD with home O2: Patient has baseline oxygen requirement of
___ NC at home and did not wear oxygen today while buying and
drinking alcohol. She was hypoxic to the ___ on RA in the ED
that ___ improved with 2L NC to the mid ___. No symptoms of
COPD exacerbation. She was instructed to use her oxygen at all
times. Home advair, albuterol and tiotropium was continued.
# Prior incidental finding: Still need follow-up of 10mm right
apical lesion that is likely scarring. However, recommend follow
up with dedicated chest CT in 3 months to ensure stability. At
that time, the 2mm right upper lobe nodule can be reassessed.
Transitional Issues:
-Follow up CT chest in 3 months for right apical nodule
#CODE STATUS: Full
#CONTACT: HCP (neighbor) ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 100 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Acute alcohol intoxication
- Alcohol withdrawal
- COPD 02 dependent
- 10mm right apical lung lesion NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were found to
be intoxicated from alcohol. Your oxygen level was found to be
low because you were not using your oxygen. You should use your
home oxygen AT ALL TIMES. We also highly recommend that you
gradually cut back on your alcohol use and consider a detox
program.
Followup Instructions:
___
|
10415973-DS-14 | 10,415,973 | 27,948,074 | DS | 14 | 2150-11-07 00:00:00 | 2150-11-07 14:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Keflex / Ceclor
/ E-Mycin / Albumin Human / Iodine-Iodine Containing / Vioxx /
Clindamycin / ___ / regadenoson / any EKG electrode
or tape
Attending: ___.
Chief Complaint:
mechanical fall; chest pain due to rib fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___, ALF resident, presenting status post mechanical fall in her
bathroom with resultant head strike and striking the left side
of her body. Patient said that she was looking for the walker
behind her and missed it and fell striking both the left side of
her head and left side of her body. No loss of consciousness.
She is complaining of severe left chest wall pain without
shortness of breath. No abdominal pain or lower extremity pain.
No headaches, neck pain or back pain. She is not on any
anticoagulants besides aspirin 81mg.
.
In ___ pt found to have rib fracture on Chest CT. Seen by ___, who
recommends ___ obs overnight and reassess in morning to go back
to her ALF. ___ RN refused admission to ___ obs. Pt admitted to
ward obs for pain control, ___, snow storm, and d/c in AM
.
On arrival to floor pt reports pain in lateral chest wall and
neck.
.
ROS: +as above, otherwise reviewed and negative
.
Past Medical History:
1. Cervical spinal stenosis
2. Hypothyroidism
3. Pernicious anemia
4. Benign Hypertension
5. Hypercholesterolemia
6. Anxiety
7. Depression, h/o ECT
8. GERD
9. s/p hysterectomy
10. s/p L knee replacement
11. Glaucoma
13. Cataract surgery
___. Chronic low back pain ___ lumbar facet arthropathy
15. Left shoulder fracture s/p ORIF ___
Social History:
___
Family History:
Grandmother and mother had coronary artery disease and type II
diabetes.
Physical Exam:
Admission Day Exam:
Vitals: T:98 BP:138/60 P:79 R:18 O2:96%ra
PAIN: 8
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
.
.
Discharge Day Exam:
VS: 97.5, 139/62, 70, 18, 99% on RA
Pain: controlled, ___
Gen: NAD, seen ambulating in hallway with assistance of rolling
walker (baseline)
HEENT: anicteric
CV: RRR, no murmur
Pulm: CTAB/L, but unable to take deep inspiration due to chest
pain
Ext: WWP, no edema
Skin: no rash
Neuro: AAOx3, fluent speech
Psych: stable, mildly anxious, appropriate
.
Pertinent Results:
Admission Labs:
===============
___ 03:40AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 03:40AM URINE RBC-1 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0
___ 03:40AM URINE MUCOUS-RARE
.
.
IMAGING:
========
___ CT C/A/P IMPRESSION:
1. Fracture of the left lateral 11th rib. No other acute
traumatic CT findings in the chest, abdomen or pelvis.
2. 1.8 cm dense exophytic lesion off the left upper pole kidney
may represent possibly hemorrhagic or proteinaceous cyst,
however, needs to be further characterized by ultrasound to
exclude solid mass.
3. Diverticulosis without evidence of diverticulitis.
4. Three 2-3 mm pulmonary nodules do not require surveillance
in the absence of high risk factors.
.
___ CT Head IMPRESSION: No acute intracranial abnormality.
.
___ CT C-spine IMPRESSION: No cervical spine fracture or
malalignment. Degenerative changes as noted above.
.
Brief Hospital Course:
___ yo F presents for monitoring and pain control after
mechanical fall with subsequent rib fracture.
.
# Mechanical Fall, c/b left 11th rib fracture
Pt was found to have rib fracture on her trauma w/u, seen on
chest CT. There was no evidence of acute trauma to the C-spine
or head. She was seen and evaluated by ___ in the ___, and was
deemed stable to discharged to home with home ___. She was
admitted for further pain control. She did receive opioid pain
medications (Percoet and Morphine) in the ___, but became
confused, so these were not continued upon admission. She was
placed on standing Tylenol, a lidocaine patch, and PRN Tramadol
with good effect. She was able to ambulate to the Bathroom with
a rolling walker, which is baseline.
.
# Incidental findings: Of note, she had incidental findings of
small pulmonary nodules on Chest CT scan and also a lesion in
the left kidney seen on Abdominal CT scan. The kidney lesion is
possibly a cyst, but will need ___ Ultrasound by PCP to further
evaluate. In terms of the lung nodules, she appears to be
low-risk, as she denies any tobacco history or occupational
exposure, so further surveillance imaging is likely not
necessary, but will defer to PCP at ___.
.
# Chronic Medical Conditions: all stable, continued her home
meds
-Hypothyroidism
-Benign Hypertension
-Hypercholesterolemia
-Anxiety/Depression, h/o ECT
-GERD
-Glaucoma
-Cataract
.
.
TRANSITIONAL ISSUES:
1. continue pain control for left rib fracture, physical
therapy via home ___
2. ___ with PCP
3. will need follow-up imaging of kidney with renal US to ___
incidental finding seen on CT scan (see pertinent results
section)
4. consider ___ chest imaging for pulmonary nodules seen on
chest CT (see pertinent results section), however she is
relatively low-risk as she denies smoking history and also
denies occupational exposures. Will defer to PCP.
5. PENDING STUDIES AT TIME OF DISCHARGE: NONE
6. Health Care Proxy - Daughter ___ ___
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES TID
2. BuPROPion (Sustained Release) 200 mg PO QAM
3. BuPROPion (Sustained Release) 150 mg PO DINNER
4. lactobacillus acidophilus 1 billion cell oral daily
5. ClonazePAM 0.25 mg PO DAILY
6. ClonazePAM 0.25 mg PO DAILY:PRN anxiety/insomnia
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 1 TAB PO HS
11. Amlodipine 2.5 mg PO BID
12. Simvastatin 10 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
15. Pantoprazole 20 mg PO Q24H
16. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
Discharge Medications:
1. Amlodipine 2.5 mg PO BID
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES TID
3. BuPROPion (Sustained Release) 200 mg PO QAM
4. BuPROPion (Sustained Release) 150 mg PO DINNER
5. ClonazePAM 0.25 mg PO DAILY
6. ClonazePAM 0.25 mg PO DAILY:PRN anxiety/insomnia
7. Docusate Sodium 100 mg PO BID
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 1 TAB PO HS
12. Simvastatin 10 mg PO DAILY
13. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily
Disp #*84 Tablet Refills:*0
14. Pantoprazole 20 mg PO Q24H
15. Multivitamins W/minerals 1 TAB PO DAILY
16. lactobacillus acidophilus 1 billion cell oral daily
17. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
18. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) 1 patch daily Disp
#*14 Kit Refills:*0
19. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 to 1 tablet(s) by mouth every 6 hours
Disp #*56 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left 11th rib fracture
mechanical fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital after a mechanical fall. You were
found to have a left 11th rib fracture. You were admitted to
the hospital for pain control. Your pain was controlled with
Tylenol, Tramadol (Ultram), and a lidocaine patch. You were
seen by the Physical Therapists, felt to be safe / stable for
discharge to home, and they recommended that you have home
Physical Therapy on discharge.
.
Please take your medications as listed.
.
Please see your physicians as listed.
.
Followup Instructions:
___
|
10415973-DS-16 | 10,415,973 | 22,595,252 | DS | 16 | 2153-01-11 00:00:00 | 2153-01-11 19:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Keflex / Ceclor
/ E-Mycin / Albumin Human / Iodine-Iodine Containing / Vioxx /
Clindamycin / ___ / regadenoson / any EKG electrode
or tape
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ ia a ___ y/o F w/ h/o chronic lower back pain
and bilateral radiculopathy ___ lumbar spinal stenosis as well
cervical myofascial pain syndrome presenting with pain in her
left buttock since a mechanical fall about a week ago.
As per OMR notes the patient has been seen by the ___ pain
management team and has had multiple lumbar epidural steroid
injections, but unfortunately without significant relief of
ongoing back pain. Dexamethasone was used on her injection in
___, and she presented again on ___ due to ongoing pain
where she received methylprednisolone. Her symptoms at the time
of that appointment included lower back pain with radiation to
lower legs, and at that time she had no numbness, tingling bowel
or bladder dysfunction.
Her back pain has remained stable until the fall on her left
buttock about 1 week ago. She describes getting up to urinate
around ___ and mis-judged the placement of her walker. She
denies chest pain, dizziness, pain prior to the fall. The pain
in her buttock is not worsened by any certain position. It is
relieved with oxycodone and tylenol. She states her last bowel
movement was 2 days prior to admission.
When she presented to the ED she had ___ left buttock pain
that was non-radiating and did not have relief with oxycodone,
tylenol or lidocaine patch. She normally ambulates with a walker
but at this time ___ pain can only stand and pivot with
assistance to get to the commode.
At her baseline, she has urinary incontinence intermittently and
wears a Pull-Up at night.
She denies fever, chills, worsening urinary incontinence,
urinary retention, bowel incontinence or retention. No saddle
anesthesia. No lower extremity weakness or paresthesias.
In the ED, initial vital signs were: 98.0, pulse 63, BP 127/62,
rr16 , 94% RA
- Labs were notable for:
U/A without evidence of infection
- Imaging:
___ - Pelvic XRAY
No acute fracture or dislocation is seen. The pubic symphysis
and sacroiliac joints are not widened. Mild to moderate
degenerative changes are seen at the bilateral hip joints. No
concerning osteoblastic or lytic lesion is identified. Bowel gas
partially obscures the sacrum.
IMPRESSION:
No acute fracture or dislocation. Degenerative changes.
___ - CT Lumbar Spine
1. Degenerative changes of the lumbar spine without significant
spinal canal narrowing. No fracture is identified.
2. Intermediate density exophytic lesion is identified in the
left kidney. This is grossly unchanged in size from MRI in ___.
If clinically indicated, consider ultrasound for further
evaluation.
- The patient was given:
___ 16:40 PO OxycoDONE (Immediate Release) 5 mg
___ 16:40 PO Acetaminophen 650 mg
___ 20:25 TD Lidocaine 5% Patch 1 PTCH
___ 22:13 PO OxycoDONE (Immediate Release) 5 mg
___ 22:13 PO Acetaminophen 650 mg
In the ED, the patient did not have relief with oxycodone,
lidocaine patch or acetaminophen and so was admitted to
geriatrics service for further inpatient management.
- Consults: None
Vitals prior to transfer were: 97.8, pulse 56, BP 145/70, rr18,
94% RA
Upon arrival to the floor, the patient noted improvement of her
pain. She was given an additional dose of 2.5mg oxycodone
shortly after arrival for ongoing discomfort.
REVIEW OF SYSTEMS:
[+] per HPI
[-] Denies headache, visual changes, pharyngitis, rhinorrhea,
nasal congestion, cough, fevers, chills, sweats, weight loss,
dyspnea, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, hematochezia, dysuria, rash, paresthesias,
weakness
Past Medical History:
1. Cervical spinal stenosis
2. Hypothyroidism
3. Pernicious anemia
4. Benign Hypertension
5. Hypercholesterolemia
6. Anxiety
7. Depression, h/o ECT
8. GERD
9. s/p hysterectomy
10. s/p L knee replacement
11. Glaucoma
13. Cataract surgery
___. Chronic low back pain ___ lumbar facet arthropathy
15. Left shoulder fracture s/p ORIF ___
16. Left 11th rib fracture s/p fall ___
Social History:
___
Family History:
Grandmother and mother had coronary artery disease and type II
diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS - T 98.0, BP 190/74, HR 58, RR 18, O2 97% RA
GENERAL - pleasant, well-appearing elderly woman reclined in
bed, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP flat
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
BUTTOCK - Left buttock is tender to palpation around the ischial
tuberosity. Lidocaine patch in place. Rectal tone is normal.
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength 4+/5 throughout. Reflexes mute and symmetric b/l.
Toes upgoing b/l. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant, somewhat forgetful.
DISCHARGE PHYSICAL EXAM:
VITALS: 98.3 144/63 66 18 97%RA Pain ___
GENERAL: Alert, oriented, no acute distress, sitting on edge of
bed ready to ambulate to bedside commode
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
RESP: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no m/r/g
ABD: +BS, soft, ND, NT. No hepatomegaly.
BACK: Left buttock is tender to palpation around the ischial
tuberosity. TTP along the Sacral spine. Rectal exam deferred
(previously recorded regular tone on admission)
GU: no foley
EXT: TTP over L lower extremity over the lower third of the
tibia, faint bruising seen over this are, warm, well perfused,
2+ pulses, no clubbing, cyanosis or edema, no rash
NEURO: A&Ox3, CNs2-12 grossly intact, strength: hip flexion RLE
___, LLE 4+/5 limited by pain, foot flexion/extension ___
bilaterally. Toes neither up nor down going bilaterally. Able to
ambulate to bedside commode and around room, but with
significant L buttock pain. Able to pivot on both legs.
Sensation intact bilaterally. Straight legs test negative
bilaterally (pain in buttock with lifting L leg, minimal pain in
L buttock with lifting R leg).
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant, somewhat forgetful and occasionally changes story.
Pertinent Results:
ADMISSION LABS:
___ 04:15AM BLOOD WBC-6.9 RBC-3.94 Hgb-11.8 Hct-36.5 MCV-93
MCH-29.9 MCHC-32.3 RDW-13.2 RDWSD-44.0 Plt ___
___ 04:15AM BLOOD Neuts-43.3 ___ Monos-8.2 Eos-5.2
Baso-0.7 Im ___ AbsNeut-2.97 AbsLymp-2.88 AbsMono-0.56
AbsEos-0.36 AbsBaso-0.05
___ 04:15AM BLOOD ___ PTT-32.0 ___
___ 04:15AM BLOOD Glucose-98 UreaN-21* Creat-1.0 Na-143
K-3.8 Cl-108 HCO3-22 AnGap-17
___ 04:15AM BLOOD ALT-10 AST-17 CK(CPK)-41 AlkPhos-84
TotBili-0.4
___ 04:15AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.0
URINE ANALYSIS:
___ 06:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 06:15PM URINE RBC-2 WBC-6* Bacteri-NONE Yeast-NONE
Epi-1
IMAGING:
CT L-SPINE W/O CONTRAST Study Date of ___ 5:59 ___
*** UNAPPROVED (PRELIMINARY) REPORT ***
IMPRESSION:
1. Degenerative changes of the lumbar spine without significant
spinal canal narrowing. No fracture is identified.
2. Intermediate density exophytic lesion is identified in the
left kidney. This is grossly unchanged in size from MRI in
___. If clinically indicated, consider ultrasound for further
evaluation.
PELVIS (AP ONLY) Study Date of ___ 6:30 ___
FINDINGS:
No acute fracture or dislocation is seen. The pubic symphysis
and sacroiliac joints are not widened. Mild to moderate
degenerative changes are seen at the bilateral hip joints. No
concerning osteoblastic or lytic lesion is identified. Bowel
gas partially obscures the sacrum.
IMPRESSION:
No acute fracture or dislocation. Degenerative changes.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
===================================================
___ y/o female with history of chronic lower back pain and
bilateral radiculopathy ___ lumbar spinal stenosis as well
cervical myofascial pain syndrome presented with acute on
chronic pain in her left buttock and sacral spine.
ACTIVE ISSUES:
===================================================
#) Left Buttock Pain/Sacral pain: Acute on chronic pain,
possibly worsened in the setting of a mechanical fall ___ weeks
prior to admission. The patient has been followed in Pain
Clinic, and has undergone steroid injections in the past. The
last injection was around ___. Per the daughter (___),
plans are to see them in clinic again soon. On admission the
patient had no lab abnormalities. Of note, the patient had
normal rectal tone, was passing flatus, had no urinary
retention, nor saddle anesthesia. Negative straight leg raise
test bilaterally. CT imaging of the lumbar spine was performed,
which did not show any fractures or evidence for lytic lesions.
The patient had improved control after treatment in the ED with
Tylenol, low dose oxycodone, and lidocaine patch, but the
oxycodone was stopped on the floor for high risk of delirium
given patient's age and history of delirium on narcotics. The
patient was discussed with her PCP ___, and the
plan is to have her evaluated for physical therapy at her
residence, and then to to be seen in her Pain Clinic soon.
# Hypertension: BP elevated to 180s-190s/60s on admission likely
as a result of pain plus having missed her home med this past
evening. However, HTN did not resolve after her usual home dose
of amlodipine. Given Captopril 6.25mg PO x1. Subsequent SBPs to
140s-150s. Pt was continued on home Amlodipine 2.5 mg PO/NG HS,
and BP will be followed up as an outpt with her PCP ___
___. BP goal <150/90.
# Constipation: Last BM was 2 days prior to admission. Likely a
result of narcotic use. Bowel regiment in hospital consisted
of: docusate Sodium 100 mg PO BID, Senna 17.2 mg PO/NG HS, and
Polyethylene Glycol 17 g PO/NG DAILY
# Hypothyroidism: Continued on Levothyroxine Sodium 88 mcg PO/NG
DAILY
# Hyperlipidemia: Continued on home Simvastatin 10 mg PO/NG QPM
# Depression: Stable. No SI/HI during hospitalization. Continued
on home Sertraline 100 mg PO/NG NOON, OLANZapine 2.5 mg PO
DAILY:PRN agitation.
# Ophtho: S/p cataract surgery and lens replacement. Continued
on home eye drops.
TRANSITIONAL ISSUES:
===================================================
- recommend outpatient Pain Clinic evaluation/treatment with her
prior pain clinic ___).
- recommend ___ evaluation and treatment, to be coordinated by
her PCP.
- recommend judicious use of opioids. Per daughter, the patient
has been sensitive to opioids in the past, with delirium as a
complication.
- will need BP monitoring and potential adjustment of
antihypertensives.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CertaVite Senior-Antioxidant (multivit-min-FA-lycopen-lutein)
0.4-300-250 mg-mcg-mcg oral DAILY
2. Acetaminophen 650 mg PO QID
3. Acidophilus (Lactobacillus acidophilus) 10 mg oral DAILY
4. Amlodipine 2.5 mg PO HS
5. Aspirin 81 mg PO DAILY
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
7. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral BID
8. Vitamin D 400 UNIT PO BID
9. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Levothyroxine Sodium 88 mcg PO DAILY
12. ___ 128 (sodium chloride) 2 % ophthalmic TID
13. OLANZapine 2.5 mg PO DAILY:PRN agitation
14. Pantoprazole 40 mg PO Q24H
15. Senna 8.6 mg PO QHS
16. Sertraline 100 mg PO NOON
17. Simvastatin 10 mg PO QPM
18. Docusate Sodium 100 mg PO BID
19. OxycoDONE (Immediate Release) 2.5 mg PO BID:PRN pain
20. Polyethylene Glycol 17 g PO DAILY
21. Ranitidine 150 mg PO BID:PRN upset stomach
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Amlodipine 2.5 mg PO HS
3. Aspirin 81 mg PO DAILY
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
5. Docusate Sodium 100 mg PO BID
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Levothyroxine Sodium 88 mcg PO DAILY
9. OLANZapine 2.5 mg PO DAILY:PRN agitation
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY
12. Ranitidine 150 mg PO BID:PRN upset stomach
13. Senna 8.6 mg PO QHS
14. Sertraline 100 mg PO NOON
15. Simvastatin 10 mg PO QPM
16. Vitamin D 400 UNIT PO BID
17. Acidophilus (Lactobacillus acidophilus) 10 mg oral DAILY
18. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral BID
19. CertaVite Senior-Antioxidant
(multivit-min-FA-lycopen-lutein) 0.4-300-250 mg-mcg-mcg oral
DAILY
20. ___ 128 (sodium chloride) 2 % ophthalmic TID
21. OxycoDONE (Immediate Release) 2.5 mg PO BID:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
-Back pain
-Hypertension
Discharge Condition:
A&Ox3. Able to ambulate with assistance and moderate pain in
left buttock. No radiculopathy. Tender to palpation over the
sacrum and L buttock over the piriformis.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you here at ___. You were
admitted with back pain. This pain is similar to your chronic
pain. While here you had imaging of your spine (CAT scan) which
did not show any fractures.
We recommend you follow-up with your Pain Doctor, and also that
you are evaluated for Physical Therapy at your residence. We
discussed this plan with you, your daughter, and your primary
providers.
While you were in the hospital, your blood pressure was also
very high, but you did not have any symptoms from it. You were
kept on the same blood pressure medications and dosing as at
home, but please discuss this with your primary care doctor at
your next appointment.
Again, it was great to meet and care for you. We wish you the
best.
-Your ___ Team
Followup Instructions:
___
|
10415973-DS-17 | 10,415,973 | 21,681,868 | DS | 17 | 2153-09-30 00:00:00 | 2153-09-30 15:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Keflex / Ceclor
/ E-Mycin / Albumin Human / Iodine-Iodine Containing / Vioxx /
Clindamycin / ___ / regadenoson / any EKG electrode
or tape / Influenza Virus Vaccines
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ yo female with mild dementia, lumbar spinal stenosis,
HTN/HLD, corneal transplant, presenting from her assisted living
with cough, malaise and right sided chest/abdominal pain.
Hx obtained from both pt (who is a poor historian) and daughter
___. Pt was in her USOH until ___ days ago, when daughter
noticed increased fatigue and non-specific malaise. Last night
she developed a productive cough and right-sided rib/upper
abdominal pain, and complained of mild shortness of breath. She
has been afebrile and denies subjective fevers/chills/rigors,
night sweats, weight loss, nausea/vomiting/diarrhea, myalgias,
headaches.
She came into the ED where she was noted to desat on RA and was
placed on 4L initially, but eventually weaned back down to RA.
Chest x-ray and subsequent CT chest demonstrated a RML PNA. Labs
notable for mild leukocytosis (11.6), negative troponin,
unremarkable BMP. She was given IV Vancomycin/Meropenem (? due
to
hx multiple allergies).
Past Medical History:
1. Cervical spinal stenosis
2. Hypothyroidism
3. Pernicious anemia
4. Benign Hypertension
5. Hypercholesterolemia
6. Anxiety
7. Depression, h/o ECT
8. GERD
9. s/p hysterectomy
10. s/p L knee replacement
11. Glaucoma
13. Cataract surgery
___. Chronic low back pain ___ lumbar facet arthropathy
15. Left shoulder fracture s/p ORIF ___
16. Left 11th rib fracture s/p fall ___
Social History:
___
Family History:
Grandmother and mother had coronary artery disease and type II
diabetes.
Physical Exam:
Physical Exam:
VS: Afebrile and vital signs stable (reviewed in bedside
record)
General Appearance: pleasant, comfortable, no acute distress,
breathing comfortably on 2L NC
Eyes: PERLL, EOMI, s/p right corneal transplant.
ENT: no sinus tenderness, MM dry, oropharynx without exudate or
lesions
Respiratory: Dense crackles appreciated on anterior right lung
exam; clear to auscultation on posterior exam with good air
movement.
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert and oriented, Cn II-XII intact. ___ strength
throughout.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
Pertinent Results:
___ 05:28AM URINE HOURS-RANDOM
___ 05:28AM URINE UHOLD-HOLD
___ 05:28AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:28AM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 05:28AM URINE HYALINE-3*
___ 05:28AM URINE MUCOUS-RARE
___ 04:15AM GLUCOSE-116* UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-21* ANION GAP-22*
___ 04:15AM estGFR-Using this
___ 04:15AM cTropnT-<0.01
___ 04:15AM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-1.7
___ 04:15AM WBC-11.6*# RBC-3.24* HGB-9.5* HCT-29.1*
MCV-90 MCH-29.3 MCHC-32.6 RDW-12.3 RDWSD-40.5
___ 04:15AM NEUTS-79.6* LYMPHS-9.7* MONOS-8.2 EOS-1.3
BASOS-0.3 IM ___ AbsNeut-9.26*# AbsLymp-1.13* AbsMono-0.95*
AbsEos-0.15 AbsBaso-0.04
___ 04:15AM PLT COUNT-317#
___ 04:15AM ___ PTT-31.4 ___
CT CHEST:
IMPRESSION:
1. Near complete opacification of the right middle lobe. While
it is possible that this could at least in part be related to
infection, underlying malignancy would be of greatest concern
especially in light of mediastinal
adenopathy. If patient has clinical signs and symptoms of
infection, repeat
after treatment could be performed. If this is not the case,
additional
imaging to include contrast-enhanced CT scan is suggested and
can be performed at this time if no contraindication.
Additional area of opacity at the right lung base medially
should also be assessed at time of followup.
2. Moderate right-sided simple pleural effusion.
3. Stable cardiomegaly and atherosclerotic disease.
4. A partially visualized 1.8 cm left upper renal pole lesion
which is not
simple in attenuation and where seen is unchanged since ___.
This could
potentially represent a hemorrhagic or proteinaceous cyst though
is
incompletely characterized. Consider non urgent dedicated
imaging to more
fully characterize and exclude an underlying mass lesion, as
previously
recommended.
RECOMMENDATION(S): If patient has clinical signs and symptoms
of infection, repeat after treatment could be performed. If
this is not the case,
additional imaging to include contrast-enhanced CT scan is
suggested and can be performed at this time if no
contraindication. Additional area of opacity at the right lung
base medially should also be assessed at time of followup.
Consider non urgent dedicated renal ultrasound to more fully
characterize and exclude an underlying mass lesion.
Brief Hospital Course:
___ yo female with mild dementia, significant anxiety, lumbar
spinal stenosis,
HTN/HLD, corneal transplant, presenting from her assisted living
with cough, malaise and right sided chest/abdominal pain.
#Community acquired pneumonia
#Right lung mass
The patient presented with right sided chest pain and malaise.
She had a chest CT with concern for pneumonia and was therefore
started on Levaquin. She was quickly weanted to room air. She
subsequently underwent a CT chest Re-read of CT with more
concern for underlying mass. Patient with contrast allergy
therefore can not get CT without pre-treatment. Discussed with
the patient's daughter/HCP ___ who prefers a less invasive
approach and would like to treat for pneumonia and then repeat
imaging after completion on therapy. On review mass was not
visible on CXR in
___. I discussed finding of mass with PCP: ___. ___
who ___
order repeat CT scan. The patient will be discharged on Levaquin
to complete a ___nxiety, dementia:
Patient with history of severe anxiety per her daughter which
often relates to her dying or getting cancer. She was continued
on olanzapine 2.5mg TID, with PRN olanzapine for agitation.
# HTN/HLD:
Continued amlodipine and statin and baby ASA 3x weekly
# Hypothyroidism:
- Continue home synthroid
# Corneal transplant:
- Continue home eye drops
Transitional issues:
- Please repeat chest CT in ___ weeks to better asses finding in
right lung
- Consider renal ultrasound to asses partially visualized "1.8
cm left upper renal pole lesion which is not simple in
attenuation and where seen is unchanged since ___
#Code Status: Full code
#HCP: Daughter ___
___ on Admission:
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Amlodipine 2.5 mg PO HS
3. Aspirin 81 mg PO DAILY
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
5. Docusate Sodium 100 mg PO BID
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Levothyroxine Sodium 88 mcg PO DAILY
9. OLANZapine 2.5 mg PO DAILY:PRN agitation
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY
12. Ranitidine 150 mg PO BID:PRN upset stomach
13. Senna 8.6 mg PO QHS
14. Sertraline 100 mg PO NOON
15. Simvastatin 10 mg PO QPM
16. Vitamin D 400 UNIT PO BID
17. Acidophilus (Lactobacillus acidophilus) 10 mg oral DAILY
18. Calcium 600 (calcium carbonate) 600 mg (1,500 mg) oral BID
19. CertaVite Senior-Antioxidant
(multivit-min-FA-lycopen-lutein) 0.4-300-250 mg-mcg-mcg oral
DAILY
20. ___ 128 (sodium chloride) 2 % ophthalmic TID
21. OxycoDONE (Immediate Release) 2.5 mg PO BID:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
Lung mass, concerning for malignancy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with pneumonia. You had a
CT scan of your chest which also showed a possible mass. You
will need a repeat CT scan in ___ weeks to make sure that your
pneumonia has resolved. You will be discharged on antibiotics to
complete a 5 day course.
We wish you the best,
Your ___ Care team
Followup Instructions:
___
|
10415973-DS-19 | 10,415,973 | 20,949,377 | DS | 19 | 2156-10-25 00:00:00 | 2156-10-26 06:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Keflex / Ceclor
/ E-Mycin / Albumin Human / Iodine-Iodine Containing / Vioxx /
Clindamycin / ___ / regadenoson / any EKG electrode
or tape / Influenza Virus Vaccines
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 12:55AM BLOOD WBC-7.9 RBC-3.50* Hgb-10.8* Hct-33.0*
MCV-94 MCH-30.9 MCHC-32.7 RDW-12.7 RDWSD-43.7 Plt ___
___ 12:55AM BLOOD ___ PTT-31.4 ___
___ 12:55AM BLOOD Glucose-178* UreaN-16 Creat-1.3* Na-140
K-3.7 Cl-105 HCO3-21* AnGap-14
___ 12:55AM BLOOD ALT-7 AST-21 CK(CPK)-58 AlkPhos-112*
TotBili-0.4
___ 12:55AM BLOOD CK-MB-3 cTropnT-0.09* proBNP-1319*
___ 12:55AM BLOOD Albumin-4.1 Calcium-9.0 Phos-4.1 Mg-1.8
Iron-31
___ 12:55AM BLOOD calTIBC-241* VitB12-536 Folate->20
Ferritn-107 TRF-185*
___ 01:03AM BLOOD ___ pO2-49* pCO2-47* pH-7.31*
calTCO2-25 Base XS--2 Intubat-NOT INTUBA
___ 01:03AM BLOOD O2 Sat-80
CXR ___
Findings consistent with left lower lobe pneumonia. No hilar
adenopathy or parapneumonic effusion.
TTE ___
The left atrial volume index is normal. There is focal
non-obstructive hypertrophy of the basal septum with a normal
cavity size. There is normal regional and global left
ventricular systolic function. The visually
estimated left ventricular ejection fraction is 55-60%. There is
no resting left ventricular outflow tract gradient. Normal right
ventricular cavity size with normal free wall motion. Tricuspid
annular plane systolic
excursion (TAPSE) is normal. The aortic sinus diameter is normal
for gender. There is a normal descending aorta diameter. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is mild [1+] aortic regurgitation.
The mitral valve leaflets are mildly thickened with no mitral
valve prolapse.
There is mild to moderate [___] mitral regurgitation. The
pulmonic valve leaflets are normal. The tricuspid valve leaflets
appear structurally normal. There is mild [1+] tricuspid
regurgitation. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/ global biventricular systolic
function. Mild aortic regurgitation. Mild to moderate mitral
regurgitation. Mild pulmonary hypertension.
DISCHARGE LABS:
===============
___ 06:15AM BLOOD WBC-5.5 RBC-3.45* Hgb-10.4* Hct-32.3*
MCV-94 MCH-30.1 MCHC-32.2 RDW-12.5 RDWSD-42.8 Plt ___
___ 06:15AM BLOOD Glucose-108* UreaN-19 Creat-1.2* Na-143
K-4.7 Cl-104 HCO3-28 AnGap-11
___ 06:15AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Patient started on treatment for CAP on ___, should continue
with this through ___
[] Statin regimen was intensified to 40mg atorvastatin daily
given NSTEMI; started baby aspirin
[] Pt was occasionally found to be mildly hypoxic during the
night to the high ___ on RA; consider workup for OSA if within
goals of care
BRIEF HOSPITAL COURSE:
======================
___ woman with a history of aortic insufficiency, legal
blindness, dementia, who presents with tachypnea, found to have
pneumonia and NSTEMI, likely type II. Patient was treated with
IV antibiotics for pneumonia and IV heparin x 48hr for NSTEMI,
and subsequently transitioned to PO antibiotics on discharge.
ACUTE ISSUES:
=============
# Community acquired pneumonia
Patient presented with a new cough over few days, tachypnea,
normal WBC count with neutrophil predominance and CXR with LLL
consolidation
c/f PNA. Presentation was suggestive of CAP although aspiration
was also possible. Blood cultures were negative. Patient was
started on Ceftriaxone and azithromycin on ___. Pt was noted to
have a prolonged QT on EKG and subsequently azithromycin was
discontinued and doxycycline was started on ___. Patient
improved clinically, and was transitioned to PO cefpodoxime +
doxycycline. Patient should continue on this regimen upon
discharge until ___ for a total of 5 days of treatment.
# NSTEMI
Patient had a troponin elevation from 0.09 to 0.32 in the
setting of pneumonia as above. This was thought most consistent
with type II given the stress on the body in setting of
pneumonia and non-specific ST changes on EKG. However given the
rapidity of rise of the troponins, we elected to start the
patient on a heparin drip. Troponins peaked at 0.46 on ___ and
subsequently downtrended. Patient also had a TTE on ___ with
normal EF, some LV hypertrophy, mild AR, mild to mod MR and mild
pulmonary HTN. After 48 hours the heparin drip was discontinued.
Patient was initiated on aspirin and her statin dose was
increased.
- Started ASA 81. Increased home atorvastatin to 40 mg
(previously on 10)
# Dementia
# Anxiety
Patient with underlying dementia with agitation while inpatient
___ hospital delirium. Patient was kept on delirium precautions
and frequently re-oriented. UA was negative. Patient was
continued on home Buspar, sertraline, and olanzapine.
CHRONIC ISSUES:
===============
# Glaucoma
Continue home eye drops
# Normocytic anemia - Hb 10.8 on admission, appeared chronic
with
prior hemoglobin between ___. Vitamin B12 and folate were
within normal limits and iron/TIBC ratio was 12.9%.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Vitamin D ___ UNIT PO 1X/WEEK (MO)
3. Acetaminophen 650 mg PO QID
4. Simvastatin 10 mg PO QPM
5. Senna 17.2 mg PO QHS
6. Sertraline 100 mg PO DAILY
7. OLANZapine 2.5 mg PO TID
8. Loratadine 10 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. Levothyroxine Sodium 88 mcg PO DAILY
11. BusPIRone 12.5 mg PO TID
12. Timolol Maleate 0.25% 1 DROP LEFT EYE BID
13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QHS
14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 1 tablet
oral BID
15. Pantoprazole 20 mg PO DAILY
16. Acidophilus Probiotic (acidophilus-pectin, citrus) 1 tablet
oral DAILY
17. Brinzolamide 1% Ophth (*NF* ) 1 drop Other BID
18. ___ 128 (sodium chloride) 2 % ophthalmic (eye) TID
19. Bion Tears (PF) (dextran 70-hypromellose (PF)) ___ drops
ophthalmic (eye) TID:PRN
20. Docusate Sodium 100 mg PO BID
21. Oxymetazoline 2 SPRY NU BID:PRN nosebleeds
22. Ranitidine 150 mg PO BID:PRN reflux
23. TraMADol 25 mg PO BID:PRN Pain - Moderate
24. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
25. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*3
Tablet Refills:*0
4. Doxycycline Hyclate 100 mg PO BID
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*3 Tablet Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Acetaminophen 650 mg PO QID
7. Acidophilus Probiotic (acidophilus-pectin, citrus) 1 tablet
oral DAILY
8. Bion Tears (PF) (dextran 70-hypromellose (PF)) ___ drops
ophthalmic (eye) TID:PRN
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
10. Brinzolamide 1% Ophth (*NF* ) 1 drop Other BID
11. BusPIRone 12.5 mg PO TID
12. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 1 tablet
oral BID
13. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QHS
14. Docusate Sodium 100 mg PO BID
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. Levothyroxine Sodium 88 mcg PO DAILY
17. Lisinopril 5 mg PO DAILY
18. Loratadine 10 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. ___ 128 (sodium chloride) 2 % ophthalmic (eye) TID
21. OLANZapine 2.5 mg PO TID
22. Oxymetazoline 2 SPRY NU BID:PRN nosebleeds
23. Pantoprazole 20 mg PO DAILY
24. Ranitidine 150 mg PO BID:PRN reflux
25. Senna 17.2 mg PO QHS
26. Sertraline 100 mg PO DAILY
27. Timolol Maleate 0.25% 1 DROP LEFT EYE BID
28. TraMADol 25 mg PO BID:PRN Pain - Moderate
29. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Community acquired pneumonia
NSTEMI
Dementia
Anxiety
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted to the hospital because you were breathing
very fast and had a worsening cough.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were found to have pneumonia. We started you on
antibiotics for this - you will continue on antibiotics when you
leave.
- You were found to have some elevated lab tests that correspond
to stress on the heart. We believe this strain on your heart was
caused by the pneumonia rather than a heart attack. However, to
be safe we kept you on a medication through the IV for 48 hours
to treat for a possible heart attack. We also started you on a
baby aspirin daily and increased your atorvastatin dose. You
should continue these when you leave the hospital.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Followup Instructions:
___
|
10416137-DS-7 | 10,416,137 | 23,660,831 | DS | 7 | 2163-01-15 00:00:00 | 2163-01-15 16:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cephalosporins / Erythromycin
Base / Penicillins / sodium bensoate
Attending: ___.
Chief Complaint:
R elbow pain
Major Surgical or Invasive Procedure:
___ closed reduction and splinting R elbow
___ ORIF R distal humerus
History of Present Illness:
Pt is R hand dominant woman who was in normal stat of health
until the morning of presentation when she slipped on the ice
and landed on an outstretched arm with immeidate pain in her
right elbow. She was seen at ___ and diagnosed with
dislocated elbow with distal humerus fracture.
Past Medical History:
TMJ, anxiety
Social History:
No tobacco, no recreational drugs, very rare alcohol
Physical Exam:
admit:
T-97.7HR- 94BP- 109/62RR- 16SaO2- 100
A&O x 3
Calm and comfortable, very anxious
BUE skin clean and intact
Tender over right elbow with posterior deformity. Mild
tenderness over R shoulder without focality. Skin intact.
Arms and forearms are soft
Significant pain with passive motion R elbow. Mild pain with
passive ROM R shoulder
Radial/Median/Ulnar/Axillary SITLT with mildly reduced sensation
compared to right.
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
Fires biceps/triceps/deltoid
d/c:
AFVSS
splint c/d/i
incision c/d/i
___ intact m/r/u
wwp, radial pulse 2+
Pertinent Results:
___ 04:00PM URINE HOURS-RANDOM
___ 04:00PM URINE HOURS-RANDOM
___ 04:00PM URINE UCG-NEGATIVE
___ 04:00PM URINE UHOLD-HOLD
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have fx/dislocation of R elbow which was reduced successfully
in the ED, after which the pt remained NVI. The ps was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF R distal humerus, which the
patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with OT who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is NWB in the RUE extremity, and will
be discharged on lovenox 40mg x2wks for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subq daily Disp #*14 Syringe
Refills:*0
4. Fluoxetine 40 mg PO DAILY
5. Senna 1 TAB PO BID:PRN constipation
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hrs Disp #*84 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
R elbow fx/dislocation
Discharge Condition:
stable
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- NWB RUE
Followup Instructions:
___
|
10416331-DS-9 | 10,416,331 | 23,576,271 | DS | 9 | 2171-01-18 00:00:00 | 2171-01-22 11:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pallor, fatigue and shortness of breath
Major Surgical or Invasive Procedure:
Upper endoscopy
Colonoscopy
History of Present Illness:
___ h/o iron deficiency anemia and hiatal hernia pw increasing
SOB x2 days. Patient states on ___ she began experiencing
symptoms consistent with a viral syndrome including fevers,
fatigue, myalgias, rhinorrhea and dry cough. Presented to ___
office and diagnosed as such, told to initiate supportive care.
She was taking aspirin or ibuprofen ___ per day for 4 days. On
___, she began being noticably pale, feeling increasingly short
of breath with any type of activity, walking 10ft to the
bathroom. Denies CP, palpitations, melena, BRBPR. She has been
diagnosed by PCP with iron deficiency anemia in ___ and was
scheduled for outpatient endoscopy in ___. Baseline Hct is
47. Presented to PCPs on ___ who performed ECG (nl) and CXR
(nl). Denies any vaginal bleeding, was evaluated by
gynecologists in ___, had negative guiac.
Past Medical History:
hypertension
hyperlidemia
depression
iron deficiency anemia
hemorrhoids
hiatal hernia dx EGD ___ years ago
colonoscopy ___ years ago
vaginal bleeding with D&Csx4 ___ years ago
Social History:
___
Family History:
Father died of lung cancer. Mother in her sleep.
Physical Exam:
Admission Physical Exam:
Vitals: T:98.4 BP:130/90 P:80 R:20 O2:100RA
General: Alert, oriented, no acute distress. Pale appearing
HEENT: Sclera anicteric, MMM, oropharynx clear, pale conjunctiva
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, EOMI intact, PERRLA. Non focal.
Skin: No rashes or lesions. Spots of dry rough skin.
DRE: No skin lesions. Normal tone. No stool in vault. Negative
guiac.
Discharge exam
VS - 98.3 121/87 80 16 99% RA
General: middle aged female laying supine in NAD
HEENT: MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding,
Ext: Warm, well perfused, 2+ pulses, no edema
Pertinent Results:
ADMISSION LABS
==============
___ 02:36PM BLOOD WBC-9.8 RBC-4.67 Hgb-9.0* Hct-30.9*
MCV-66* MCH-19.4* MCHC-29.3* RDW-18.3* Plt ___
___ 02:36PM BLOOD Neuts-61.1 ___ Monos-6.2 Eos-5.4*
Baso-0.9
___ 02:36PM BLOOD Plt ___
___ 06:45AM BLOOD Ret Aut-2.2
___ 06:45AM BLOOD Ret Aut-2.2
___ 07:40PM BLOOD Glucose-105* UreaN-26* Creat-1.1 Na-140
K-3.6 Cl-105 HCO3-24 AnGap-15
___ 07:40PM BLOOD ALT-15 AST-18 LD(LDH)-179 AlkPhos-68
TotBili-0.1
___ 07:40PM BLOOD Lipase-138*
___ 07:40PM BLOOD Albumin-4.3 Iron-11*
___ 07:40PM BLOOD calTIBC-465 ___ Ferritn-4.3*
TRF-358
DISCHARGE LABS
==============
___ 06:50AM BLOOD WBC-7.2 RBC-4.95 Hgb-10.0* Hct-33.5*
MCV-68* MCH-20.1* MCHC-29.8* RDW-18.1* Plt ___
___ 06:45AM BLOOD Neuts-56.2 ___ Monos-6.4 Eos-8.3*
Baso-0.8
___ 06:50AM BLOOD Glucose-86 UreaN-12 Creat-0.9 Na-141
K-4.1 Cl-105 HCO3-24 AnGap-16
___ 06:50AM BLOOD Phos-4.1 Mg-2.8*
ENDOSCOPY
==============
EGD ___
Impression:
Large complex hiatal hernia
Erythema in the gastroesophageal junction compatible with
esophagitis (biopsy)
Erythema in the fundus and stomach body
Erythema in the antrum compatible with gastritis (biopsy)
Normal mucosa in the third part of the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
COLONOSCOPY ___
Impression:
Normal mucosa in the whole colon
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
PATHOLOGY
===========
Gastrointestinal mucosal biopsies, three:
A. Gastroesophageal junction:
Squamous mucosa with active esophagitis and surface erosion;
scant cardiac-type mucosa within normal limits.
B. Gastric antrum:
Predominantly antral mucosa, within normal limits.
C. Duodenum:
Small intestinal mucosa, within normal limits.
Brief Hospital Course:
Assessment and Plan: A ___ h/o iron deficiency anemia and hiatal
hernia admitted with sypmtomatic anemia and found to have
erosive gastritis.
.
# Anemia of acute blood loss- Microcytic, with known iron
deficiency affecting production. However the recent 4pt drop in
Hct was concerning for acute losses. Retic count is 2.2, which
is insufficiently elevated given her anemia. Production is
likely limited from iron deficiency but could also be suppressed
from recent viral infection. Hemolysis labs LDH, bili and hapto
normal. She was transfused 1unit PRBC with symptom improvement
and appropriate rise in Hct which remained stable throughout her
hospital course, with Hct of 33.5 at discharge, up from a nadir
of 26.1 prior to transfusion. EGD and colonoscopy revealed
linear erosions from her hiatal hernia as the most likely
etiology of GI bleeding and subsequent anemia. Prior to
discharge we began iron supplementation with Ferrous Sulfate and
vitamin C, to be continued in an outpatient setting. The patient
will follow up with her PCP ___ 1 week for a repeat Hct to
assess for stability/resolution of her anemia.
# Iron Deficiency: Though iron deficiency is likely the result
of chronic gastrointestinal bleeding, celiac disease was also
considered a possible explanation. As an outpatient, screening
for celiac disease with anti-TTG and total IgA is recommended
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Diltiazem Extended-Release 300 mg PO DAILY
hold for SBP <100
2. Butalbital Compound *NF* (butalbital-aspirin-caffeine)
50-325-40 mg Oral PRN migraine
3. Venlafaxine XR 150 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
Please take 1 pill daily as tolerated for 1 week, then
transition to 2 pills a day. Please take 2 hours before or 4
hours after your PPI. Please take with vitamin C.
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
2. Ascorbic Acid ___ mg PO DAILY
Please take with each ferrous sulfate pill.
RX *ascorbic acid ___ mg 1 tablet(s) by mouth dialy Disp #*30
Tablet Refills:*0
3. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice daily Disp #*60
Capsule Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Please take as needed for constipation related to iron
supplementation.
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 dose by
mouth daily Disp #*1 Bottle Refills:*0
5. Venlafaxine XR 150 mg PO DAILY
6. Butalbital Compound *NF* (butalbital-aspirin-caffeine) 50 mg
ORAL PRN migraine
7. Diltiazem Extended-Release 300 mg PO DAILY
hold for SBP <100
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: iron deficiency anemia and occult
gastrointestinal bleeding
Secondary diagnoses: Complex hiatal hernia with linear erosions
Discharge Condition:
Hemodynamically stable, alert and oriented x3, ambulating
independently without assistive devices.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for fatigue and
shortness of breath. Your blood tests showed anemia consistent
with iron deficiency, however the acute drop in your blood
counts and evidence of blood in your stool prompted further work
up for a possible source of bleeding. You were given a blood
transfusion with marked improvement in your symptoms and your
blood count remained stable.
You had a upper endoscopy and colonoscopy which showed a large
complex hiatal hernia with linear erosions, which may be the
cause of your anemia. You will be treated with iron
supplementation and a proton pump inhibitor at home. You should
follow up with your PCP ___ 1 week to get a repeat complete
blood count to monitor your anemia. You should also have tests
for celiac disease at your PCP's office, including anti-tissue
thyroglobulin (anti-TTG) and total IgA.
If you experience increased weakness, shortness of breath upon
exertion, lightheadedness, a racing heart rate, black stool, or
bright red blood in your stool you should return to the ED
immediately.
MEDICATION CHANGES
START Ferrous sulfate
START Vitamin C
START Omeprazole
START Miralax
Followup Instructions:
___
|
10416447-DS-8 | 10,416,447 | 29,777,250 | DS | 8 | 2162-01-05 00:00:00 | 2162-01-05 14:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
L5/S1 Epidural Steroid Injection
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of
sciatica/back pain since an injury in ___ in ___
(helping with ___. Approximately 5
days ago he was working on his roof, felt a similar "pop" and
developed crippling low back pain radiating down his right leg,
complicated by an inability to walk. He presented to the ED 2
days prior for pain control and was discharged with oral
narcotics & non-narcotic meds that were effective. However,
given that he has a history of heroin abuse (generally clean ___
years although using again since ___ on suboxone, he was
apparently unable to fill his prescriptions (perhaps due to a
Mass Health regulation). He returned to the Emergency Room
today for further pain control.
In the ED, initial vital signs were 98.4 76 122/85 14 99% RA.
Patient was given percocet, diazepam & ibuprofen with good pain
control.
On the floor, ___ feels improved with pain ___, better
after ___ on transfer. He denies numbness of lower
extremities (except ___ & ___ toe of Left foot, old injury),
tingling, weakness, loss of bladder or bowel continence. He
also denies chest pain, dyspnea, nausea, vomiting, recent
illness, falls, injury. He does have constipation x4 days.
Review of sytems:
Otherwise negative except as above
Past Medical History:
HIV
Substance abuse
Social History:
___
Family History:
No family history of back pain, discitis, osteomyelitis,
infections, diabetes, hypertension
Physical Exam:
Vitals- 98.0 140/78 80 18 98%RA
General- Well appearing, intermittently uncomfortable. alert,
oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple,
Lungs- Clear to auscultation bilaterally
CV- Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no edema
Neuro- CNs2-12 intact, motor function grossly normal, lower
extremity full ROM< ___ strength, sensation intact
Pertinent Results:
LAB DATA:
___ 04:20PM BLOOD ___ PTT-34.4 ___
___ 04:20PM BLOOD WBC-6.5 RBC-4.51* Hgb-13.8* Hct-40.3
MCV-89 MCH-30.6 MCHC-34.3 RDW-13.3 Plt ___
MRI L-SPINE:
1. Left-sided formainal/extraforaminal disc herniation at L4-5,
possibly
contacting the L4 nerve root.
2. Posterior annular tear of the L5-S1 disc with herniation and
bilateral
neural foraminal narrowing.
Brief Hospital Course:
1. Acute on chronic low back pain: MRI showed left-sided
formainal/extraforaminal disc herniation at L4-5 and a posterior
annular tear of the L5-S1 disc with nerniation and bilateral
neural foraminal narrowing. Initially he was treated with
NSAIDs, oxycodone and diazepam. When this provided only minimal
improvement, oral steroids were provided, followed by an
epidural injection. After the injection the patient improved
though remained unable to climb the stairs required for a
discharge to home.
Given the patient's history of prior IV drug abuse, avoidance of
long-term opiates was a goal. He was therefore transitioned to
tramadol and flexeril (the latter which causes some drowsiness).
An increase in his outpatient suboxone dose was considered but
his outpatient prescriber could not be reached. He continued on
tramadol and flexeril along with ___ with improvement and will be
discharged home on these medications although he will contact
his outpt doctor to consider increasing the suboxone to use for
this pain.
2. Anxiety/Depression: Reported situation anxiety depression,
relating to his being in the hospital and being essential
immobile. Psychiatry evaluated the patient and felt there were
no indications for inpatient treatment. He will follow up with
his outpatient psychiatrist
Medications on Admission:
Suboxone 8 mg-2 mg PO BID
Discharge Medications:
1. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Acute on chronic low back pain secondary to lumbar
radiculopathy
2. HIV
3. Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with worsening of your chronic back pain. To
help treat this an epidural steroid injection was performed.
You received physical therapy and will continue to do so at
home, it is also going to be important to set up an appt with an
outpatient physical therapist once not homebound for further
improvement
Followup Instructions:
___
|
10416634-DS-8 | 10,416,634 | 24,978,082 | DS | 8 | 2184-12-10 00:00:00 | 2184-12-10 13:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain and fever
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ yo female who was in ___ unti ___ when she developed
___ epigastric gain which worsened eating. This did not
improve despite Prilosec 20 daily with some relief when it was
increased to 40 mg but then in the last ___ her sx worsened
despite being on Prilosec. She was diagnosed with a UTI in ___
for which she was treated. In the last two weeks she was
treated with cipro 1000 mg daily for another UTI when she
presented with dizziness and cold sweats along with back pain,
she never had dysuria. ___ She had recurrent temp spikes
whenever the Tylenol wears off. She has also had recurrent non
bloody - non bilous emesis. She had one small soft stool
yesterday. No recent strange foods or foreign travel. Her
roomate was sick last week with flu like sx. Yesterday was last
day of cipro. She had some white foamy vaginal discharge but
this has improved.Of note she presented to the ED 2 days ago
with fever to 102. She had a negative abdominal CT and was thus
discharged.
..................
The GI service requested a complete abdominal ultrasound, heart
emergency department radiologist will not perform this scan
given the duration of such a scan, and the fact that she was so
thoroughly imaged on her last ED visit. Thus, we will defer that
to inpatient. At the request of the admitting hospitalist she
had an RUQ in the ED to rule out cholangitis.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger:
[x] cbc, chem7, lipase
[x] ivf, pain control
Disposition/Pending: admit med for GI workup
Admission Vitals:
In ER: (Triage Vitals:
9 98.8 103 111/60 16 100%
)
Meds Given: toradol
Fluids given: 2L NS
Radiology Studies: RUQ US
consults called: none
.
PAIN SCALE: ___ location:
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ ] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ +] ___8__ lbs. weight loss over the course of two weeks
Eyes
[X] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT []
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ -] Sore
throat [] Sinus pain [ ] Epistaxis [ ] Tinnitus [+] new
nasal congestion x 1 day
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [x] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ +]
Chest Pain- ___ chest pressure because she is congested from
a cold [- ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ +] Nausea [+] Vomiting [+] Abd pain [] Abdominal swelling
[ ] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [x] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [x] All Normal
[ ] Rash [ ] Pruritus
MS: [] All Normal
[ X] Joint pain - exacerbation of chronic aches and pains
secondary to sports while on cipro. [ ] Jt swelling [ ]
Back pain [ ] Bony pain
NEURO: [] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[+ ] Headache - she doesn't usually get them but associated with
uTi
ENDOCRINE: [x] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [x] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [x] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
[ ]Medication allergies [ ] Seasonal allergies
[x]all other systems negative except as noted above
Past Medical History:
anxiety
arthroscopic shoulder surgery.
Her wisdom teeth have been removed x4.
Social History:
___
Family History:
Her family history is adopted. She does not
know much, although she does know her biological mother had
reflux.
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
VITAL SIGNS:
GLUCOSE:
PAIN SCORE
1. VS: T 97.6 P 71 BP 114/68 RR 18O2Sat on 100% on RA
ht, BMI
GENERAL: Thin female laying in bed
Nourishment: OK
Grooming: OK
Mentation: OK
2. Eyes: [X] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [X] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [X] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None [] Bruit(s), Location:
[X] Edema LLE None [] PMI
[] Vascular access [x] Peripheral [] Central site:
5. Respiratory [X]
[X] CTA bilaterally [ ] Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ X] WNL
[] Soft/firm [] Rebound [] No hepatomegaly [] Non-tender []
Tender [] No splenomegaly
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL [x]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [X] WNL
[ ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
[] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [] WNL
[] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated
[] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
11. Hematologic/Lymphatic [ ]WNL
[] No cervical ___ [] No axillary ___ [] No supraclavicular ___
[] No inguinal ___ [] Thyroid WNL [] Other:
12. Genitourinary [] WNL
[ ] Catheter present [x] Normal genitalia [ ] Other:
No CMT
TRACH: []present [X]none
PEG:[]present [X]none [ ]site C/D/I
COLOSTOMY: :[]present [X]none [ ]site C/D/I
.
Pertinent Results:
___ 08:30PM URINE HOURS-RANDOM
___ 08:30PM URINE HOURS-RANDOM
___ 08:30PM URINE UCG-NEGATIVE
___ 08:30PM URINE GR HOLD-HOLD
___ 08:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG
___ 08:30PM URINE RBC-0 WBC-5 BACTERIA-MOD YEAST-NONE
EPI-4
___ 06:23PM LACTATE-1.2
___ 06:08PM GLUCOSE-83 UREA N-7 CREAT-0.8 SODIUM-137
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
___ 06:08PM ALT(SGPT)-86* AST(SGOT)-101* ALK PHOS-74 TOT
BILI-0.8
___ 06:08PM LIPASE-63*
___ 06:08PM ALBUMIN-4.3
___ 06:08PM D-DIMER-2505*
___ 06:08PM WBC-5.5 RBC-4.01* HGB-12.5 HCT-36.9 MCV-92
MCH-31.1 MCHC-33.8 RDW-12.7
___ 06:08PM NEUTS-56 BANDS-0 ___ MONOS-6 EOS-1
BASOS-0 ATYPS-10* ___ MYELOS-0
___ 06:08PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 06:08PM PLT SMR-LOW PLT COUNT-131*
-----
FINDINGS:
CT OF THE ABDOMEN WITH IV CONTRAST:
A hypodensity is noted in the left lobe of the liver (2:24),
which is too
small to characterize. Otherwise, the liver, gallbladder,
spleen, pancreas,
stomach, visualized loops of small and large bowel, bilateral
adrenal glands,
and bilateral kidneys are normal. There is no free fluid or free
air in the
abdomen. There is no mesenteric or retroperitoneal
lymphadenopathy. The
abdominal aorta is normal in caliber and contour.
CT OF THE PELVIS WITH ORAL AND IV CONTRAST: The bladder appears
distended
with fluid. The uterus, sigmoid colon and rectum are normal.
Normal appendix
is identified (300:22). There are few prominent inguinal lymph
nodes but are
not meeting criteria for pathologic enlargement. There is no
pelvic
lymphadenopathy.
OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous
lesions
suspicious for malignancy.
IMPRESSION: No evidence of acute abdominal or pelvic processes.
Admission RUQ US:
ReportIMPRESSION: There is slight prominence of the echogenicity
of the portal
Preliminary Reportvenous structures. Correlation with labs and
clinical history is recommended
Preliminary Reportto rule out hepatitis. Otherwise, normal right
upper quadrant ultrasound.
___ 7:30 am IMMUNOLOGY
**FINAL REPORT ___
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test v2.0.
Detection Range: ___ copies/mL.
This test is approved for monitoring HIV-1 viral load in
known
HIV-positive patients. It is not approved for diagnosis of
acute HIV
infection.
In symptomatic acute HIV infection (acute retroviral
syndrome), the
viral load is usually very high (>>1000 copies/mL). If
acute HIV
infection is clinically suspected and there is a
detectable but low
viral load, please contact the laboratory for
interpretation.
It is recommended that any NEW positive HIV-1 viral load
result, in
the absence of positive serology, be confirmed by
submitting a new
sample FOR HIV-1 PCR, in addition to serological testing.
___ 6:40 am SEROLOGY/BLOOD CHEM# ___ ___.
**FINAL REPORT ___
MONOSPOT (Final ___:
POSITIVE by Latex Agglutination.
(Reference Range-Negative).
___ 06:15AM BLOOD WBC-9.7 RBC-3.39* Hgb-10.7* Hct-31.1*
MCV-92 MCH-31.7 MCHC-34.5 RDW-12.7 Plt ___
___ 06:40AM BLOOD WBC-7.8 RBC-3.65* Hgb-11.3* Hct-33.2*
MCV-91 MCH-31.1 MCHC-34.2 RDW-12.9 Plt ___
___ 07:30AM BLOOD WBC-5.4 RBC-3.55* Hgb-11.4* Hct-32.2*
MCV-91 MCH-32.0 MCHC-35.3* RDW-13.0 Plt ___
___ 07:30AM BLOOD ESR-51*
___ 06:15AM BLOOD ALT-186* AST-170* TotBili-0.9
___ 06:40AM BLOOD ALT-202* AST-196* LD(LDH)-443*
TotBili-0.9
___ 07:30AM BLOOD ALT-119* AST-135* AlkPhos-96 TotBili-0.9
___ 06:08PM BLOOD ALT-86* AST-101* AlkPhos-74 TotBili-0.8
___ 07:30AM BLOOD CRP-44.3*
___ 07:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
___ 06:08PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-NEGATIVE IgM HAV-NEGATIVE
___ 07:30AM BLOOD HIV Ab-NEGATIVE
___ 06:40AM BLOOD Acetmnp-NEG
___ 07:30AM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
# Viral syndrome: She had a sick contact, constitutional
symptoms suggestive of viral syndrom, and LFT abnormalities. A
Monospot was positive, suggesting acute EBV infection. LFTs
peaked prior to discharge. She will refrain from
tylenol/alcohol. OCPs were discontinued (see below).
# Abdominal Pain, chronic: Epigastric. MAde worse by acute
viral syndrom w/ N/V. EGD showed gastritis only. GI consult
thought perhaps chronicity due to oral contraceptive use,
initiation of which coincided with onset. This was discontinued.
She will inform her GYN doc. She will continue PPI for one
month.
# LFT abnormality: due to acute mono. She will have repeat
tests with PCP.
Medications on Admission:
OCPs
Omeprazole
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): for 1 month
only.
Discharge Disposition:
Home
Discharge Diagnosis:
Viral syndrome, unspecified
Chronic abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fever, runny nose, malaise, nausea,
vomiting, mild liver abnormalities and low platelet count
suggestive of a viral infection, and chronic abdominal pain. A
CT scan of the chest was normal without evidence for blood clot.
Ultrasound was normal. Endoscopy revealed mild gastritis for
which you should continue the Omeprazole for now. A Monospot
was positive, suggesting you had acute ___ Virus
infection. The abdominal pain may be from your oral
contraceptive which was discontinued. You should discuss this
with your OB/GYN doctor. Your PCP should repeat liver function
blood work at your next appointment. Please refrain from
tylenol and alcohol until normal.
You have chronic abdominal pain since ___, and will still
need to follow up with your GI physician for an endoscopy.
Followup Instructions:
___
|
10417104-DS-10 | 10,417,104 | 28,724,977 | DS | 10 | 2184-08-27 00:00:00 | 2184-08-30 12:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Carbamazepine
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old male with history of post-traumatic
seizures reportedly left frontal in origin, who presents with
following a typical seizure, in the setting of recent stressors
and dental work. History notable for recent homelessness and
significant family stressors.
Mr. ___ reports he has been in his usual state of health
until this evening. He was in a local bar with his friends, and
had not yet had anything to drink. He remembers having a ___
sensation, which is a typical aura prior to his seizures, and
then does not remember anything until waking up with EMS. By
EMS
report, the patient was with a friend, who recognized that he
was
going to have a seizure, and laid him to the ground in the right
lateral recumbent position. He had a generalized convulsion
lasting approximately 2 minutes. By the time of EMS arrival, he
was oriented to name only, and was pale and diaphoretic. No
tongue biting or bowel/bladder incontinence. He was brought to
___ ED for further evaluation.
Since being at ___ ED the patient has had unremarkable vitals
and has slowly been returning to baseline. He reports that he
feels at his baseline now apart from generalized tooth pain and
soreness in his calves, the latter of which is typical for his
seizures.
Of note, the patient had been homeless for much of the last
year.
His father had taken him into his home for the last month, but
about 1.5 weeks ago, the patient says he was unable to stay with
him longer, due to him having to be hospitalized for surgery and
have his own health issues to deal with. He has been homeless
since. He also had recent dental work done. When obtaining
additional details of this, the patient is reluctant to provide
history saying, "Leave me alone, I am sick of all these
questions." He reports he had a "deep root cleaning" of a
tooth,
for which he did not receive anesthesia. He is not sure whether
this happened days ago, a month ago or more. He completed a
course of amoxicillin afterwards. Otherwise, he denies any
recent
medication changes, missed medication doses, trauma, or
infections.
SEIZURE HISTORY
Per Dr. ___ ___, discussed and verified with patient:
"Was in an ___ at age ___ with TBI in L frontal lobe. Started
having seizures at age ___ s/p EEG and MRI that reportedly
confirmed that they are coming from his L frontal lobe.
Initially
treated with very high doses of Carbamazepine and Depakote that
lead to side effects of hair loss, tremor, double vision. These
doses were decreased when he switched epileptologists and these
side effects improved but are still present at times. He has
noted cognitive and memory issues he thinks as a result of
his seizures."
SEIZURE SEMIOLOGY
"Pt is not sure how long his seizures usually last and has
apparently not gotten a good description of how they usually
appear to bystanders. He always gets aura of ___, feeling
hot or cold. He is amnestic of the events but to his
understanding, he can either just lose consciousness and drop or
he can drop and then have whole body convulsive movements
leading
to injury. + Tongue biting or urinary incontinence. +Post ictal
confusion."
SEIZURE FREQUENCY AND POSSIBLE TRIGGERS
Reports having seizures anywhere between once per week to once
per month.
Patient notes he was on carbamazepine in the past but was taken
off about a year ago due to not tolerating side effects.
Past Medical History:
Epilepsy
Social History:
___
Family History:
No genetic/idiopathic epilepsy.
Physical Exam:
Physical Exam:
Vitals: 97.8F, HR 86, BP 160/70, RR 16, O2 98% RA
General: Awake, irritable but cooperative with encouragement,
NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused; regular on telemetry
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. The pt had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Patient declined due to "leg soreness."
****
DISCHARGE EXAM:
Unchanged
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 03:50PM 8.5 4.56* 14.1 42.9 94 30.9 32.9 13.9
47.9* 201 Import Result
___ 06:05AM 8.7# 4.11* 12.7* 38.1* 93 30.9 33.3 13.9
47.2* 171 Import Result
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im
___ AbsLymp AbsMono AbsEos AbsBaso
___ 03:50PM 77.6* 14.4* 6.4 0.6* 0.4 0.6 6.56*
1.22 0.54 0.05 0.03 Import Result
___ 06:05AM 67.6 18.2* 12.6 0.6* 0.5 0.5 5.91#
1.59 1.10* 0.05 0.04 Import Result
BASIC COAGULATION ___, PTT, PLT, INR) Plt Ct
___ 03:50PM 201 Import Result
___ 06:05AM 171 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 03:50PM 130* 10 1.0 138 4.6 98 21* 24* Import
Result
___ 06:05AM ___ 135 4.3 100 24 15 Import Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ 06:05AM Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 03:50PM 12 30 82 0.5 Import Result
___ 06:05AM 10 17 66 0.4 Import Result
OTHER ENZYMES & BILIRUBINS Lipase
___ 03:50PM 15 Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
___ 03:50PM 4.6 Import Result
___ 06:05AM 4.0 Import Result
NEUROPSYCHIATRIC Valproa
___ 10:18PM 46* Import Result
___ 03:50PM 87 Import Result
___ 06:05AM 24* Import Result
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Acetmnp Bnzodzp Barbitr
Tricycl
___ 10:18PM NEG NEG NEG NEG NEG Import Result
IMAGING:
___:
1. No acute intracranial abnormalities.
2. Severe sinusitis with complete opacification of the frontal,
maxillary sinus and ethmoid air cells with evidence of fungal
colonization in the maxillary sinus.
CXR: No acute process
Brief Hospital Course:
___ year old male with history of post-traumatic seizures
reportedly left frontal in origin, who presents with multiple
breakthrough seizures in the setting of medication
non-compliance, though he denies this. He had a VPA level of 24
on admission. He was restarted on his home VPA and monitored for
1 day and returned to baseline. He
Social work was recommended for stressors of homelessness, but
patient wished to leave hospital prior to this meeting.
He also endorsed dental pain and had evidence of sinusitis on CT
scan, which had been evaluated by ENT in the ED, so patient was
continued on Amoxicillin per their recommendations. It was
recommended that he stay inpatient for work-up of possible
dental abscess but he declined and patient elected to leave AMA.
He was given a prescription for VPA 1000mg BID which was
confirmed with his neurologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (EXTended Release) 1000 mg PO BID
Discharge Medications:
1. Divalproex (EXTended Release) 1000 mg PO BID
RX *divalproex ___ mg 2 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with multiple seizures. The levels of
your Depakote in your blood was low, suggesting that you may not
be taking your medication. You were urged to take your
medication and given a prescription as well. We called your
neurologist and he was concerned you may not be taking your
medications. It is very important that you follow-up with him at
the appointment scheduled below.
We were also concerned about an infection such as sinusitis or a
dental infection. You were given antibiotics in the emergency
room and should continue taking them for 10 days and follow-up
with ENT to make sure this resolved.
We recommended that you stay in the hospital to get further
evaluation and speak with our social worker, but you declined.
You were discharged AGAINST MEDICAL ADVICE.
Your ___ Neurologists
Followup Instructions:
___
|
10417104-DS-11 | 10,417,104 | 29,693,327 | DS | 11 | 2186-05-13 00:00:00 | 2186-05-13 18:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Carbamazepine
Attending: ___.
Chief Complaint:
Reason for Consultation: concern for seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
___ is a ___ year old man with a past medical
history
of TBI at age ___ with post-traumatic epilepsy, anxiety,
depression, who presents with elevated mood and responding to
internal stimuli.
Patient's boyfriend ___ provides history, says that he was
last
completely himself on ___ afternoon. During that day,
___
was having leg pain, and so they presented to the ED for
evaluation in the ED on ___ and were later discharged
home. ___ has been saying things like "do we [people]
communicate through hair?". ___ feels that ___ mood is
elevated, and he hasn't seen ___ behaving like this before.
They went to see the PCP on ___ who was concerned about how
he was acting.
In terms of patient's seizures, he has been having clusters of
seizures every 3 weeks. The last was ___ to ___ of this
past weekend. The first two were GTC which were about 5 minutes
long with postictal state, and the other 4 were episodes of
confusion. The last one on ___ heard something drop in
the kitchen and ___ was walking around aimlessly, then said
he wanted to sleep and slept on the kitchen table.
When ___ is asked about his symptoms, he says that he has
been having new episodes. He says he can "hear everything, I can
hear all these other sounds". He doesn't respond when asked if
he
is hearing voices, but rather makes strange gestures with his
arms. His partner denies previous episodes of elevated mood. He
does not answer when asked if he has missing periods of time in
his memory. On ___ morning, patient started Keppra (this was
a prescription from the ___ previously, that patient had
previously refused to start). He has taken 2 doses so far. Mood
and behavioral changes began before Keppra was started. He
denies
any ___. The episodes that he is currently experiencing are
not similar to the seizure events documented in by patient's
outpatient neurologist.
Epilepsy history from clinic note:
Typical events:
Type 1:
___ without impaired awareness, occur a few times per week
Type 2:
___ with loss of awareness, occur less than once per week
Type 3:
Aura: ___, electric feeling in left? hand
Ictal: staring, unresponsive, then bilateral arm stiffening and
leg bicycling movement
TB/incont: Y/Y
Postictal: difficulty breathing, groggy for 15 minutes
First: ___ yo
Frequency: ___ times per month
Precipitants: stress, anxiety
AED / other therapy trials:
carbamazepine: up to 600mg BID in the past, ineffective? rash?
levetiracetam: up to 2g BID in the past, ineffective?
valproate: current (hair loss, tremor). dose decreased from 1.5g
BID to 1.5 g daily in ___ due to supratherapeutic level
Current seizure control: not well controlled
Special features:
Status epilepticus: unknown
Seizure flurries: Y
Hospitalizations/ ER visits for seizures: Y
Self-injury during seizures: Y
Fall risk: High
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies difficulty with gait.
On general review of systems, the pt denies recent illness or
fever or chills. Denies cough, shortness of breath. Denies
chest
pain. Denies nausea, vomiting, abdominal pain.
Past Medical History:
PMH/PSH:
aortic coarctation
epilepsy
TBI
anxiety
depression
Past Psychiatric History:
patient denies previous psychosis or mania
Social History:
___
Family History:
FAMILY HISTORY:
uncle has epilepsy due to TBI
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 97.9 HR 90 BP 141/86 RR 18 SaO2 98% RA
General: Awake, uncooperative, agitated.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx
Neck: Supple, no carotid bruits appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl.
Abdomen: soft, NT/ND
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self ___, hospital. He
cannot relay history reliably. When speaking, he says he is
hearing things, and then makes arm movements as if he is playing
a violin. When asked yes/no questions he answers, but will not
elaborate. He is very suspicious, asking multiple times with
every request why he should do this. He was able to able to
repeat. Able to follow commands intermittently. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects in the stroke card. He describes stroke card
picture in good detail. He is able to read without difficulty.
Speech was not dysarthric. There was no evidence of neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2 2 2
R 2+ 2+ 2 2 2
Plantar response was flexor bilaterally. Pectoral spread
bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Able to heel
walk and toe walk.
Pertinent Results:
Laboratory Data:
___ 05:35PM BLOOD WBC: 9.9 RBC: 4.39* Hgb: 13.2* Hct: 40.7
MCV: 93 MCH: 30.1 MCHC: 32.4 RDW: 12.8 RDWSD: 43.___
___ 05:35PM BLOOD Neuts: 59.8 Lymphs: ___ Monos: 9.4 Eos:
0.8* Baso: 0.5 Im ___: 0.2 AbsNeut: 5.91 AbsLymp: 2.90 AbsMono:
0.93* AbsEos: 0.08 AbsBaso: 0.05
___ 05:35PM BLOOD Glucose: 97 UreaN: 7 Creat: 0.6 Na: 140
K:
3.8 Cl: 101 HCO3: 26 AnGap: 13
___ 05:35PM BLOOD Calcium: 10.1 Phos: 3.5 Mg: 1.7
___ 05:35PM BLOOD Valproa: 87
___ 05:35PM BLOOD ASA: NEG Ethanol: NEG Acetmnp: NEG
Tricycl: NEG
IMAGING:
Non-Contrast CT of Head ___
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or
mass. The
ventricles and sulci are normal in size and configuration.
There is no evidence of acute fracture. New since ___, there is
complete opacification of the right maxillary sinus, right
anterior and
posterior ethmoid air cells and right frontal sinus. The
maxillary sinus
opacification demonstrate heterogeneous density, possibly
representing fungal
colonization. The medial wall of the maxillary sinus is
demineralized with
evidence demineralization of the right uncinate process. There
is no evidence
of thinning of the inner wall of the right frontal sinus. The
visualized
portion of the remaining paranasal sinuses, mastoid air cells,
and middle ear
cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. No acute intracranial abnormalities.
2. Severe sinusitis with complete opacification of the frontal,
maxillary
sinus and ethmoid air cells with evidence of fungal colonization
in the
maxillary sinus.
Brief Hospital Course:
___ is a ___ year old man with a past medical
history of TBI at age ___ with post-traumatic epilepsy, anxiety,
depression, who presented with elevated mood and responding to
internal stimuli. Admitted to Epilepsy to rule out seizure as
underlying some of his behavioral changes. Keppra was
discontinued as it may have contributed to his psychosis. He was
seen by psychiatry who recommended psychiatric hospitalization
once he was medically cleared. EEG was performed and there was
no electrographic correlate to his behavioral outbursts. There
was one electrographic seizure out of sleep originating from the
right temporal region, and this had no electrographic correlate.
Zonisamide was started at 100mg daily with a plan to uptitrate
by 100mg daily every week up to goal of 300mg daily. He has had
no seizure on EEG for >24 hours. He will follow-up with Dr. ___
___ in epilepsy clinic following his psychiatric
hospitalization.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. LevETIRAcetam 750 mg PO BID
2. Lisinopril 5 mg PO DAILY
3. Divalproex (EXTended Release) 1500 mg PO DAILY
Discharge Medications:
1. Zonisamide 100 mg PO DAILY Duration: 6 Doses
Start: Today - ___, First Dose: Next Routine Administration
Time
This is dose # 1 of 2 tapered doses
2. Zonisamide 200 mg PO DAILY Duration: 7 Doses
Start: After 100 mg DAILY tapered dose
This is dose # 2 of 2 tapered doses
3. Zonisamide 300 mg PO DAILY
Start: After last tapered dose completes
This is the maintenance dose to follow the last tapered dose
4. Divalproex (EXTended Release) 1500 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Psychosis
Epilepsy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
you were admitted due to concerning behavioral changes. An EEG
ruled out that these were caused by seizure. Psychiatry
evaluated you and felt you needed further inpatient psychiatric
care. Because Keppra may have contributed to the behavioral
changes, this was stopped and you were started on zonisamide
instead. You were monitored on EEG and had one electrographic
seizure while you were asleep, with no other clinical events.
Please continue zonisamide 100mg daily, then after 1 week
increase to 200mg daily, and after another week increase to
300mg daily. Please follow-up in epilepsy clinic with Dr. ___
___.
It was a pleasure taking care of you,
Your ___ Neurology Team
Followup Instructions:
___
|
10417160-DS-18 | 10,417,160 | 27,052,887 | DS | 18 | 2160-12-06 00:00:00 | 2160-12-06 14:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Benadryl / Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
TEE/Cardioversion
History of Present Illness:
___ female with PMH of Afib and dCHF as well as recent THR in
___, brought in from ___ due to worsening
shortness of breath and hypoxia. Has been treated for PNA since
___ with Cefepime. Lasix has been given prn over last few
days. Despite that patient has had increasing dyspnea and
increased oxygen requirements.
In the ED, initial vitals were 97 76 147/97 20 94% 3L. She was
given vanc/cefepime, lasix 40 x 2, and sublingual nitroglycerin
0.3 x 1 with slight improvement in her dyspnea. CXR showed
pulmonary edema (although cannot exclude infection) and
bilateral pleural effusions. Labs were notable for BNP of 5000,
WBC 11.3, Cr 1.8, Na 121 and trop 0.06. She was admitted to ___
for CHF exacerbation.
On the floor, she complains of ___ R hip pain, which she
reports has been intermittent since her THR in ___. Her
dyspnea slightly improved with treatment in the ED. She denies
fevers/chills, cough, orthopnea, but endorses leg swelling and
PND x 1 week. She says she has been short of breath since her
operation.
Past Medical History:
1. CARDIAC RISK FACTORS:
Atrial fibrillation diagnosed ___, now status post
successful cardioversion on amiodarone with DCCV, ___, on
coumadin.
Diabetes
Dyslipidemia
Hypertension
History of diastolic CHF with EF 50%
Moderate mitral regurgitation
Hypertriglyceridemia
2. CARDIAC HISTORY:
Cardioversion
3. OTHER PAST MEDICAL HISTORY:
Chronic kidney disease with baseline crt 2.2-2.5
Possible COPD per V/Q scan
Pneumonia ___ leg fracture ___
Macular degeneration, legally blind
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
================
VS: 97.5 163/83 91 24 95% 3L 88.6kg bed
General: Obese, lying on her right side, moaning from pain in R
hip
HEENT: NCAT, MMM
Neck: supple
CV: irregular, no m/r/g
Lungs: Bibasilar crackles, otherwise clear.
Abdomen: soft, NT/ND.
Ext: WWP, 3+ pitting edema to thighs bilaterally, ~10cm incision
at R hip c/d/i, w/ steri-strips still in place.
Sacrum: 4 x 5 cm irregularly shaped sacral ulcer, stage III-IV.
Neuro: moving all extremities grossly
DISCHARGE EXAM:
================
VS: 98.3 140s-180s/50s-80s ___ 18 88-95% RA
Wt 78.8 from 76.3 kg 88.6 on admission
I/O 740/700, ___
Tele: Afib
General: Obese, sitting at bedside comfortably
Neck: no JVD at 60 degrees
CV: RRR, no m/r/g
Lungs: dry bibasilar crackles, mild expiratory wheezes.
Abdomen: soft, NT/ND.
Ext: WWP, no edema, ~10cm incision at R hip c/d/i, w/
steri-strips still in place, 2cm deep tissue injury at L heel.
Sacrum: 4 x 5 cm irregularly shaped sacral skin breakdown
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS:
================
___ 12:00PM BLOOD WBC-11.3* RBC-3.20* Hgb-9.4* Hct-30.0*
MCV-94 MCH-29.3 MCHC-31.2 RDW-15.0 Plt ___
___ 12:00PM BLOOD Neuts-87.8* Lymphs-5.8* Monos-5.3 Eos-0.8
Baso-0.3
___ 12:00PM BLOOD ___ PTT-44.1* ___
___ 12:00PM BLOOD Glucose-146* UreaN-51* Creat-1.8*#
Na-121* K-4.7 Cl-86* HCO3-22 AnGap-18
___ 12:00PM BLOOD proBNP-5321*
___ 12:00PM BLOOD cTropnT-0.06*
___ 07:00PM BLOOD Mg-2.3
___ 12:07PM BLOOD Lactate-1.2
DISCHARGE LABS:
================
___ 06:45AM BLOOD WBC-13.4* RBC-3.10* Hgb-9.3* Hct-29.3*
MCV-94 MCH-29.9 MCHC-31.6 RDW-14.6 Plt ___
___ 06:45AM BLOOD ___ PTT-68.2* ___
___ 06:45AM BLOOD Glucose-232* UreaN-58* Creat-1.6* Na-137
K-4.3 Cl-92* HCO3-33* AnGap-16
___ 06:45AM BLOOD Mg-1.9
STUDIES:
================
___ TTE:
The left atrial volume is moderately increased. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Doppler parameters are most consistent with Grade
II (moderate) left ventricular diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Moderate diastolic LV
dysfunction. Mild aortic and mitral regurgitation.
___ CT Chest w/o con:
Diffuse ground glass opacities and septal thickening likely
represent
hydrostatic edema. Superimposed peribronchovascular and
subpleural mixed
attenuation opacities may reflect asymmetrical edema or a
coexisting
infection. Drug toxicity from amiodarone is considered less
likely given rapid and substantial improvement since the CXR of
___. Recommend followup conventional CXR in 3 to 5 days to
document resolution.
___ TEE:
No echocardiographic evidence of spontaneous echo contrast or
thrombus in either atria or atrial appendages. Mild aortic
regurgitation. Mild-moderate mitral regurgitation. Normal global
left ventricular systolic function. Complex atheroma in the
descending aorta.
___ CXR PA/L:
Comparison is made with prior studies chest x-ray and CT from
___.
There is mild cardiomegaly. There is increase in mediastinal
fat. Small
bilateral effusions are larger on the left side, unchanged from
prior studies.
Extensive bilateral diffuse, ill-defined opacities largely in
the upper lobe are unchanged. Differential diagnosis still
includes asymmetric edema with co-existent infection, much less
likely amiodarone toxicity.
Brief Hospital Course:
___ female with PMH of Afib and dCHF as well as recent THR in
___, brought in from ___ due to worsening
shortness of breath and hypoxia, felt to be due to CHF exac.
#dCHF exac: Likely due to inconsistent and inadequate diuretics.
She was diuresed from an admission weight of 89 kg to a
discharge dry weight of 77 kg. Placed on torsemide 20 daily for
maintenance. Continued metop XL at 100.
#Afib: She underwent TEE/cardioversion for atrial fibrillation
with restoration of normal sinus rhythm. Discontinued amiodarone
for ?pulm toxicity. Her INR was subtherapeutic for several days,
despite increasing doses of warfarin. She was covered by a
heparin drip in house, and will be discharged on an enoxaparin
bridge until her INR becomes therapeutic.
#Hypoxia: She continued to be mildly hypoxic after diuresis, so
CT Chest was performed, which showed some non-specific
consolidations. Pulmonary was consulted and recommended
discontinuing amiodarone for possible pulmonary toxicity. She
will follow up with pulmonary as an outpatient for PFTs and
repeat imaging.
#Hyponatremia: Likely hypervolemic hyponatremia given slow trend
downwards from 137 on ___ with accumulation of fluid. She was
hyponatremic to 121 on presentation. This corrected to normal
with diuresis.
#Leukocytosis: Intermittently elevated to ___ during this
admission. She was afebrile, without localizing symptoms, no
cough or diarrhea. UA/UCx were negative x 2. Most likely caused
by inflammation from sacral pressure ulcer.
#Sacral pressure ulcer, stage III: Followed by wound care.
Treated with dressings and miconazole powder.
#CKD: Cr was 1.6 on ___ at rehab, and 1.6 here for the last
several days of the admission.
#DM2: Held home oral agents. HISS while in house. Restarted
orals at discharge.
#HTN: Continued amlodipine and metop. Added lisinopril 2.5mg.
Transitional Issues:
-Continue enoxaparin bridge until INR therapeutic at 2.0-3.0.
-Added lisinopril 2.5mg. Recheck renal function/potassium in 1
week.
-Torsemide 20 daily for maintenance diuresis.
-Discontinued amiodarone for ?pulm toxicity.
-F/u w/ outpatient pulm for PFTs.
# CODE: Full.
# EMERGENCY CONTACT: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
2. Acetaminophen 1000 mg PO Q8H
3. Warfarin 0.5 mg PO DAILY16
4. Amiodarone 200 mg PO BID
5. Collagenase Ointment 1 Appl TP BID to sacral ulcer
6. Ferrous Sulfate 325 mg PO BID
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. GlipiZIDE 10 mg PO BID
9. Amlodipine 10 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. CefePIME 2 g IV Q24H
12. Cyanocobalamin 500 mcg PO DAILY
13. fenofibrate 145 mg oral daily
14. Metoprolol Succinate XL 100 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. linagliptin 5 mg oral daily
17. Pioglitazone 15 mg PO DAILY
18. Ibuprofen 600 mg PO Q6H
19. Senna 8.6 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO BID
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
6. Lidocaine 5% Patch 1 PTCH TD QAM
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Senna 8.6 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 4 mg PO DAILY16
12. Enoxaparin Sodium 30 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
13. Miconazole Powder 2% 1 Appl TP DAILY
14. Torsemide 20 mg PO DAILY
15. Collagenase Ointment 1 Appl TP BID to sacral ulcer
16. fenofibrate 145 mg oral daily
17. GlipiZIDE 10 mg PO BID
18. linagliptin 5 mg oral daily
19. Pioglitazone 15 mg PO DAILY
20. Polyethylene Glycol 17 g PO DAILY
21. Lisinopril 2.5 mg PO DAILY
22. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute diastolic congestive heart failure
Atrial fibrillation
Sacral pressure ulcer, stage III
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted for an exacerbation of your congestive heart
failure. You were treated with intravenous diuretics to remove
excess fluid. You underwent cardioversion for your atrial
fibrillation and normal sinus rhythm was restored. You had a CT
scan of your lungs, which showed changes concerning for lung
disease. Therefore, your amiodarone was discontinued due to
concerns for lung toxicity. You should follow up with
pulmonology as below for formal lung function testing.
Followup Instructions:
___
|
10417160-DS-19 | 10,417,160 | 29,833,923 | DS | 19 | 2161-01-06 00:00:00 | 2161-01-06 13:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Benadryl / Sulfa(Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
urinary tract infection and altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of type 2 diabetes, HFpEF, right total hip
arthroplasty ___, and A fib status post DCCV (___) and
discharge from ___ (___) where she was treated for AFib
and decompensated CHF. During her last admission she had
amiodarone held for concern for possible pulmonary toxicity, was
cardioverted, and diuresed from 89 kg to 77 kg. She was placed
on torsemide 20 daily for maintenance, continued metop XL at
100, and continued systemic anticoagulation. TEE last admission
showed EF >55%, E/e___ with moderate diastolic dysfunction,
1+MR, and 1+AR.
She was discharged to ___ where she was feeling well until
this morning when she was noted to have a heart rate in the
140s. She denies any shortness of breath, palpitations, PND,
orthopnea, chest pain, fevers, chills, cough, abdominal pain.
She notes urinary frequency and nausea today without emesis. She
denies dysuria. She had Ecoli grow at ___ and
initially was not on abx until today when ceftriaxone started.
Reports normal p.o. intake.
ED COURSE:
Triage 12:35 0 97.4 140 127/68 18 96% 2L Nasal Cannula
Today 18:39 0 99.0 111 154/82 18 98% Nasal Cannula
-20g IV
-Blood cx
-Urine cx
-Metop 5mg IV x4
-Metop 25mg PO x2
-APA 325mg
-Zofran 2mg
-Ceftriaxone 1g- based on ___ sensitivities
-500mL NS
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
1. CARDIAC RISK FACTORS:
#Atrial fibrillation diagnosed ___: CHADS2 = 4. Successful
cardioversion on amiodarone with DCCV, ___ and ___,
on coumadin.
#Diabetes type II
#Dyslipidemia
#Hypertension
#History of diastolic CHF with EF 50%
#Moderate mitral regurgitation
#Hypertriglyceridemia
#2. CARDIAC HISTORY:
#Cardioversion
#3. OTHER PAST MEDICAL HISTORY:
#Chronic kidney disease with baseline crt 2.2-2.5
#Possible COPD per V/Q scan
#Pneumonia ___
#Right leg fracture ___
#Macular degeneration, legally blind
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: 99.2 130/80 120 AF 18 98% 3L
General: Elderly woman lying in bed in NAD
HEENT: Dry lips, dentures
Neck: no JVD
CV: Irreg, tachycardic, no m/r/g
Lungs: Rales at left base, otherwise clear, moving good air
without wheezes, no e/o effusion
Abdomen: Obese, nt, nd
GU: no foley, no CVAT
Ext: Warm, no edema. 2+ DP pulses. 2x2cm pressure ulcer L heel
with eschar. Well healed R hip surgical scar.
Neuro: A&Ox3. Decreased visual acuity grossly. PERRL, EOMI, w/o
nystagmus, tongue midline, face symmetric. Shrug symmetric. 4+
strength in all major muscle groups symmetrically. 2+ DTRs
throughout. Negative pronator, no tremor.
Skin: 5x5 cm pressure ulcer with granulation tissue and no
surrounding erythema in superior gluteal cleft
DISCHARGE EXAM:
98.1, 120-160/60-80 HR ___ on tele, afib RR 16 96-100% 4L NC
General: Elderly obese woman in NAD, appears more comfortable
than previously
HEENT: EOMI, sclera anicteric
Neck: JVP not appreciable
CV: Irregularly irregular, no murmurs appreciated
Lungs: consolidation on left with improved movement, mild
wheezes
Abdomen: Nondistended, nontender
GU: No foley
Ext: No edema of legs
Neuro: Alert and oriented x 3, but confused about situation
(patient is legally blind), below her baseline per her daughter
PULSES: Unable to appreciate DP pulses bilaterally
Pertinent Results:
ADMISSION LABS
--------------
___ 01:29PM BLOOD WBC-16.1* RBC-3.03* Hgb-9.0* Hct-28.5*
MCV-94 MCH-29.6 MCHC-31.5 RDW-15.5 Plt ___
___ 01:29PM BLOOD Neuts-90.1* Lymphs-4.2* Monos-5.1 Eos-0.5
Baso-0.2
___ 01:29PM BLOOD ___ PTT-33.0 ___
___ 01:29PM BLOOD Glucose-216* UreaN-76* Creat-2.5* Na-133
K-4.4 Cl-93* HCO3-21* AnGap-23*
___ 01:29PM BLOOD Albumin-3.6 Calcium-9.4 Phos-3.3 Mg-2.4
___ 01:39PM BLOOD Lactate-2.0
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-11.9* RBC-2.94* Hgb-8.8* Hct-27.9*
MCV-95 MCH-30.0 MCHC-31.6 RDW-16.0* Plt ___
___ 06:00AM BLOOD ___
___ 06:00AM BLOOD Glucose-171* UreaN-70* Creat-2.0* Na-139
K-4.1 Cl-99 HCO3-28 AnGap-16
MICROBIOLOGY
------------
___ Blood Culture x2: PENDING
___ Blood Culture x2: PENDING
___ Urine Culture:
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING
-------
___ CXR:
FINDINGS: AP and lateral views of the chest were obtained with
patient
positioned upright. In comparison with prior chest radiographs
and chest CT, there is improvement in scattered opacities seen
on prior exam with
near-complete resolution. There are coarsened interstitial
markings which could represent component of fibrosis. No new
consolidation is seen. No effusion or pneumothorax. Patient
rotation limits evaluation of the mediastinum. The heart size
appears grossly stable and top normal in overall size. The
imaged osseous structures appear intact.
IMPRESSION: Interval improvement in previously noted scattered
pulmonary
opacities. There is a probable component of fibrosis likely
accounting for interstitial coarsening.
___ CXR:
FINDINGS: As compared to the previous radiograph, assessment
for volume
overload.
COMPARISON: ___.
As compared to the previous radiograph, the moderate
cardiomegaly and the
signs of mild fluid overload persist. In addition, there is a
zone of
increased parenchymal opacity at the left lung base, combined to
air
bronchograms and minimal blunting of the costophrenic sinus.
Findings are highly suggestive of newly occurred pneumonia.
___
LEFT FOOT, THREE PORTABLE VIEWS No previous foot films on PACS
record for
comparison.
There is a subtle soft tissue defect along the posterior aspect
of the lower heel. There is degenerative spurring of the
calcaneus posteriorly and inferiorly. The posterior spurring is
compatible with insertional Achilles tendinopathy. However, the
underlying calcaneus is within normal limits. No bone erosion
or sclerosis suggestive of osteomyelitis. Diffuse osteopenia
and vascular calcifications are noted.
IMPRESSION: No radiographic evidence of osteomyelitis. In
particular, no changes suggestive of osteomyelitis in the
calcaneus.
___ Renal U/S:
The right kidney measures 10.9 cm and the left kidney measures
10.2 cm. There is some bilateral cortical thinning. No
hydronephrosis is seen in either kidney. No perinephric fluid
collection is identified. No cyst or stone or solid mass is
identified bilaterally. The urinary bladder is partially
distended and is normal in appearance.
IMPRESSION:
No hydronephrosis and no fluid collection identified
bilaterally.
Brief Hospital Course:
TRANSITIONAL ISSUES:
- last dose of levaquin ___
- monitor Cr, oxygen requirement and volume status to determine
diuretic regimen. Patient is euvolemic on discharge, so goal
weight should be rehab admission weight.
- needs close monitoring of INR while on levofloxacin. Currently
on home warfarin 4mg daily which was restarted ___.
- ensure patient is seen by Dr. ___ her stay at ___
___ for pacemaker placement
- keep metoprolol 100mg Q6h and diltiazem 30mg Q6h and hold for
HR<70. HRs <110 should be tolerated. Do not convert the
medications to long acting to avoid bradycardia if patient were
to convert to sinus.
-Patient is discharged on 2.5 L oxygen, please titrate down to
02 sat >93%
ASSESSMENT AND PLAN: ___ yo woman with HFrEF, AF w/ RVR s/p DCCV
___, recent total hip arthroplasty ___ who was recently
discharged ___ to ___ Rehab after DCCV and diuresis for
decompensated CHF who presents with AF w/ RVR, found to have
pneumonia. Now rate controlled with metoprolol and diltiazem,
will get a pacemaker in the next few weeks.
#Pneumonia: Patient with evolving consolidation on x-ray, cough,
focal sounds on exam, and continual hospitalization for several
months and leukocytosis to 26 on admission. Consistent with HCAP
pneumonia. Probably partially treated with ceftriaxone. ___
account for increased 02 requirement
-Now on levaquin q 48 hours, WBC improving, 02 sat improving,
exam better, has never mounted a fever
-Last dose ___
#UTI likely based on u/a (+leuks, WBC, -nitrites), but paucity
of symptoms.
-Treated with HCAP coverage if real versus just colonization
#Atrial fibrillation with RVR: CHADS2=4. Had DCCV ___ with
conversion to NSR. Amiodarone was d/c'd for concern for
pulmonary toxicity. Current AF may be worsened by infection.
Rate control is difficult in that patient has history of
bradycardia when in sinus, so converting is dangerous without
pacemaker. Currently plan is to convert tomorrow, and hold beta
blockers, potentially but in a pacemaker. Preserved EF on last
echo, can give dilt.
- metoprolol 100 mg q 6 hours increased to 100mg, and diltiazem
30 mg q 6 hours, hold for HR <70
- coumadin with INR goal ___, daily INR
- Sotalol is off the table with worsening renal function
- Is being evaluated by Dr. ___ from the
Electrophysiology Department at ___ for pacemaker placement.
He will see the patient at rehab
#Heart failure exacerbation: Triggered for AF w/ RVR to 150 ___
___. Repeat CXR with hint of L sided effusion, but not
particularly changed. Dry weight last admission 77kg, rcvd 500mL
___ for bed wt 77kg and ___ thought to be prerenal. Dyspneic at
baseline, unclear if exacerbation.
-Continue home lasix 60 mg daily, has been euvolemic for several
days
#Acute on chronic renal failure. CKD stage III/IV. eGFR ~30.
Baseline Cr 1.6-1.8 and 1.6 at last discharge. 2.5 on admission.
Most likely pre-renal (overdiuresis versis sepsis) given exam
and increased Lasix at SNF. Discharge weight last admission
77kg. Weighs 77kg here (bed weight, likely overestimate).
Concern for renal obstruction: renal u/s, negative
-hold lisinopril
#Type 2 diabetes: 144-303 (10 Humalog). Hold linagliptin,
glipizide, pioglitazone prior to ___ admission, though rehab
not giving glitazone or gliptin.
--Now on glargine 10 units started ___, will likely need to
be increased am glucose goal of 100-120 when eating more
--start Humalog sliding scale
#Sacral and heel ulcers: Poor prognostic signs of progress at
rehab. Do not appear to be infected on admission or during
hospitalization. Wound care was consulted about proper
treatment. X-ray of heel not consistent with chronic
osteomyelitis.
-Can continue with Mepilex for now but be sure to mold into
depths
of wound to adhere to entire wound bed
-Pressure ulcer care per protocol
-roho cushion when sitting - limit sit time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Cyanocobalamin 500 mcg PO DAILY
3. Ferrous Sulfate 325 mg PO BID
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Senna 8.6 mg PO BID
___ MD to order daily dose PO DAILY16
8. fenofibrate 145 mg oral daily
9. GlipiZIDE 5 mg PO BID
10. linagliptin 5 mg oral daily
11. Polyethylene Glycol 17 g PO DAILY
12. Lisinopril 2.5 mg PO DAILY
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob
14. Tamsulosin 0.4 mg PO HS
15. Miconazole Powder 2% 1 Appl TP DAILY
16. Furosemide 60 mg PO BID
17. Vitamin D 1000 UNIT PO DAILY
18. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ferrous Sulfate 325 mg PO BID
2. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob
3. Multivitamins 1 TAB PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. Warfarin 4 mg PO DAILY
8. Diltiazem 30 mg PO Q6H
Hold for heart rate <70. Do not convert to long acting.
9. Docusate Sodium 100 mg PO BID
10. Levofloxacin 750 mg PO Q48H
Last dose on ___.
11. Metoprolol Tartrate 100 mg PO Q6H
Hold for heart rate <70. Do not convert to long acting.
12. Sarna Lotion 1 Appl TP TID:PRN itching
13. TraZODone 50 mg PO HS insomnia
14. fenofibrate 145 mg oral daily
15. Tamsulosin 0.4 mg PO HS
16. Miconazole Powder 2% 1 Appl TP DAILY
17. Lisinopril 2.5 mg PO DAILY
18. Furosemide 60 mg PO DAILY
19. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
20. Acetaminophen 650 mg PO Q8H:PRN pain
21. Cyanocobalamin 500 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Atrial fibrillation with RVR
HCAP pneumonia
___ on CKD
Discharge Condition:
Mental Status: Confused sometimes
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted because you had a fast heart rate called atrial
fibrillation and appeared ill. At first we thought that this had
happened because of a UTI (urinary tract infection). When you
did not get better, we were worried that you might have another
infection, and you had signs of pneumonia on exam and chest
xray. We started you on antibiotics for this, and you got
better. The next step to discuss is a pacemaker, which will
prevent you from going into atrial fibrillation again.
Our cardiology team will follow you at ___
Center and will determine when the best time for pacemaker
placement is. We are hopeful that this can happen next week.
Followup Instructions:
___
|
10417160-DS-21 | 10,417,160 | 28,926,211 | DS | 21 | 2161-05-03 00:00:00 | 2161-05-05 11:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Benadryl / Sulfa(Sulfonamide Antibiotics) / Oxycodone / Sulindac
Attending: ___
Chief Complaint:
L face and arm weakness with gaze deviation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is an ___ white woman with PMH of
chronic atrial fibrillation on warfarin, ___ (LVEF >55%),
mild-moderate MR, DM2, HTN, HLD and CKD, with recent AV node
ablation and pacemaker insertion in ___, who presents with
sudden-onset L face & arm weakness w/R gaze deviation today. The
pt reports feeling well until this morning, and per her
daughters, has not been complaining of any neurologic,
cardiopulmonary or systemic symptoms recently. Of note, her INRs
have been running low recently and she got extra warfarin doses.
This morning around 10 AM the pt was getting up to go weigh
herself on a scale. She was with her daughter at the time, who
noticed that Ms. ___ had difficulty ambulating and using her
L arm. Initial glc 115, BP 177/96 HR 80 sat 97%RA.
Past Medical History:
# Atrial fibrillation diagnosed ___: CHADS2 = 4, on
warfarin. Successful cardioversion on amiodarone with DCCV,
___ and ___ s/p recent AV node ablation and
pacemaker insertion in ___
# Diabetes type II-insulin dependent on glargine and sliding
scale
# Dyslipidemia
# Hypertension
# Diastolic CHF with EF 50%
# Moderate mitral regurgitation
# Hypertriglyceridemia
# Chronic kidney disease with baseline crt 2.2-2.5
# Possible COPD per V/Q scan
# Pneumonia
# Right leg fracture
# Macular degeneration, legally blind
# Total hip arthroplasty ___
Social History:
___
Family History:
No family history of early stroke or MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
97.6 80 157/136 20 97%
General: NAD, lying in bed comfortably.
- Head: NC/AT, no conjunctival pallor or icterus, no
oropharyngeal lesions
- Neck: Supple with some limited ROM, no nuchal rigidity.
- Cardiovascular: RRR, no M/R/G
- Respiratory: Nonlabored, clear to auscultation with good air
movement bilaterally to limited anterior exam
- Abdomen: nondistended, normal bowel sounds, no
tenderness/rigidity/guarding
- Extremities: Warm, no cyanosis/clubbing/edema
___ Stroke Scale score was: 10
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 2
3. Visual fields: 2 (left hemianopia)
4. Facial palsy: 1
5a. Motor arm, left: 2
5b. Motor arm, right: 0
6a. Motor leg, left: 1
6b. Motor leg, right: 0
7. Limb Ataxia: 1 (left arm)
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 1 (left)
Neurologic Examination:
Mental Status:
Awake, alert, oriented to month and being in hospital.
Attention: Recalls a coherent history; thought process coherent
and linear without circumstantiality and tangentiality.
Language: fluent without dysarthria and with intact repetition
and verbal comprehension. No paraphasic errors. High- and
low-frequency naming intact. Normal reading.
Cranial Nerves:
[II] Pupils: equal in size and briskly reactive to light and
accommodation. No RAPD. Visual acuity poor.
Visual fields w/dense L hemianopia
[III, IV, VI] Gaze deviation to the right, able to look left
when
told to and with passive head motion but not spontaneously or
with pursuit
[V] V1-V3 with symmetrical sensation to light touch.
[VII] L nasolabial fold flattening
[VIII] Hearing grossly intact
[IX, X] Palate elevates in the midline.
[XI] R head deviation
[XII] Tongue shows no atrophy, emerges in midline.
Motor: L arm hypotonic, drifts down w/pronation. Slight
downdrift
of L leg. Moves R side well.
Sensory: Decreased subjective sensation on left but able to
perceive pain. Extinguishes to double simultaneous stimuli.
Additionally, appears to have some stocking neuropathy.
Reflexes: hypoactive L arm, absent Achilles b/l, L plantar
upgoing.
Coordination: No R-side dysmetria
Gait& station:
deferred
Discharge exam:
MS: awake, alert, speech normal
CN: PERRLA, EOMI, mild left face weakness, tongue midline,
palate symmetric
MOTOR: strength full on right side. total paralysis of the LUE
with increased tone. Able to lift the LLE against gravity
slightly at the IP and knee. No movement more distally in foot.
SENSORY: dense sensory loss in the LUE. Endorses feeling LT in
LLE. Extinction to DSS in LLE.
Pertinent Results:
CT Head ___:
FINDINGS: No hemorrhage, edema, mass effect or acute
territorial infarction
is identified. Within the left cerebellar hemisphere, there is
a linear
hypodensity likely reflective of prior infarction, now a focus
of
encephalomalacia. Prominent ventricles and sulci reflect
age-related
involutional changes. Periventricular and confluent
hypodensities consistent
with small vessel ischemic disease. Basal cisterns are patent
and there is
preservation of gray-white matter differentiation.
No fracture is identified. Visualized paranasal sinuses,
mastoid air cells
and middle ear cavities are clear. Incidental note is made of
carotid siphon
and vertebral artery calcifications.
IMPRESSION: No acute intracranial abnormality. Left cerebellar
focus of
encephalomalacia, likely sequela of prior infarction.
CT Head ___:
FINDINGS:
There is a large hypodense area involving the right occipital
lobe and
posterior medial temporal lobe better seen on the present study
than priors
compatible with evolving infarction. There is no intracranial
hemorrhage or
mass effect. The ventricles and sulci are prominent consistent
with atrophy.
There is an old right thalamic lacunar infarct. Periventricular
white matter
hypodensities consistent with chronic small vessel ischemic
disease. There is
minimal mucosal thickening in the left maxillary sinus. The
remainder of the
paranasal sinuses mastoid air cells and middle ear cavities are
clear. There
is no suspicious osseous lesion.
IMPRESSION:
1. Evolving right PCA territory infarction. No intracranial
hemorrhage.
Clinical team is aware of the findings
NOTIFICATION: These findings were discussed with Dr. ___ by
Dr. ___
___ telephone at 2:15pm
Brief Hospital Course:
___ is an ___ F with h/o Afib on warfarin with recent
AV nodal ablation and ___ insertion in ___, ___, DM, HTN, HLD,
CKD presenting with left face and arm weakness and right gaze
deviation consistent with right MCA stroke in the setting of
subtherapeutic INR. She is s/p tPA at 11:56am on ___.
Ms. ___ was admitted to the neuroICU for close monitoring
following tPA administration. Her exam did not improve
significantly after tPA was given. Repeat head CT at 24hrs post
tPA did not show any signs of hemorrhage and was notable for
hypodensity of the right PCA territory. Blood pressure was
allowed to autoregulate and coumadin was held until 24hrs
post-tPA, when it was restarted with an 81mg aspirin as a
bridge. Aspirin should be discontinued when INR is therapeutic.
Risk factors were assessed with LDL (82) and HgbA1c (pending).
Echocardiogram did not reveal evidence of thrombus or shunt.
During the hospital course Ms. ___ home lasix (40mg once
every three days) was held and respiratory status and fluid
status were monitored clinically. This medication was not need
and therefore not restarted, although it can be restarted as
needed in the future. She was restarted on her home lisinopril
and glipizide on ___. She was evaluated by ___ who felt that she
would benefit from acute rehab. She passed a speech and swallow
evalution with a modified diet, we suggest she have a purreed
diet.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? () Yes (LDL = 82)
- (x) No
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? () Yes - (x) No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - (x) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A
====================================================
Medications on Admission:
APAP 325 mg PRN
Warfarin 2.5 mg daily
fenofibrate micronized 134 mg daily
ferrous sulfate 325 mg daily
furosemide 40 mg every 3 days
glipizide 5 mg daily
lisinopril 5 mg daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PR HS:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Lidocaine 5% Patch 1 PTCH TD QPM
6. Metoprolol Tartrate 12.5 mg PO TID
7. Senna 8.6 mg PO BID:PRN constipation
8. Warfarin 2.5 mg PO DAILY16
9. Lisinopril 5 mg PO DAILY
10. GlipiZIDE 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of left face and body
weakness resulting from an ACUTE ISCHEMIC STROKE, a condition in
which a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High blood pressure, diabetes, atrial fibrillation
We are changing your medications as follows:
1. STOPPED FUROSEMIDE
2. STARTED ASPIRIN 81mg daily, this medication should be stopped
when a therapeutic INR level is reached
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10417172-DS-17 | 10,417,172 | 25,479,593 | DS | 17 | 2163-04-17 00:00:00 | 2163-04-17 18:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Tetanus Vaccines and Toxoid / amlodipine
Attending: ___.
Chief Complaint:
dyspnea, leg edema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o F with PMhx of OSA (on CPAP),
fibromyalgia, obesity (s/p RNYGB ___ c/b afferent limb
obstruction s/p subtotal gastrectomy and small bowel resection
now with short gut syndrome (on TPN ___ years), prior UE DVT/PE
x2
(___) related to PICC line on Lovenox until ___
who p/w increasing lower extremity edema and shortness of breath
over the last 2 weeks.
The patient was recently admitted to the medicine service for
lower extremity edema and shortness of breath that was thought
to
be related to malnutrition. Her dyspnea resolved on hospital day
1. LENIs were negative. She was discharged after placement of
central line and being started on TPN and IV essential vitamins.
The patient reports that her symptoms started in the last
___.
She noted worsening of her lower extremity swelling, increasing
DOE. She reports gaining 4lbs in the past 48h. She denies any
pain/erythema of her lower/upper extremities. Denies any SOB at
rest, chest pain, cough, orthopnea, PND. No fevers or chills.
Of note, per her prior admission note, she had an exercise
stress
test and echocardiogram done at ___ approximately a month
ago, which the patient reports were within normal limits. The
patient also reports a history of DVT/PE x 2 approximately ___
years ago which were related to PICC lines. She was on Lovenox
until ___ of this year. She reports that at one point she
was told she would need lifelong anticoagulation.
- In the ED, initial VS were: 97.4, 73, 159/86, 26, 100% RA
- Exam notable for:
Cardiovascular: Normal S1, S2, regular rate and rhythm, no
murmurs/rubs/gallops, 2+ peripheral pulses bilaterally
Pulmonary: Clear to auscultation bilaterally
Extremities: 1+ pitting edema in bilateral legs
- Labs showed: Hgb 8.7, WBC 4.4 stable compared with prior
admission. Otherwise normal Chem panel and LFTs. BNP of 419 down
from 570 on prior admission
- CXR showed no evidence of pneumonia or pulmonary edema.
- EKG was notable for: NSR @ 72, with normal intervals, axis,
and
without signs of ischemia, or evidence or right heart strain.
- Transfer VS were: 97.6, 78, 126/48, 18, 100% RA
REVIEW OF SYSTEMS:
Patient also reports new onset tooth pain that is a result of
her
teeth falling out recently
Past Medical History:
- Obesity (s/p Roux-en-Y gastric bypass c/b afferent limb
obstruction now s/p multiple stomach and small bowel resections
and short gut syndrome)
- History of UE DVT/PE x2 (___) related to ___ line. On
Lovenox until ___.
- OSA on CPAP
- Depression
- Agarophobia
- Fibromyalgia
- Insomnia
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam
=======================
VS: 99, 177/98, 68, 20, 97% RA
GENERAL: NAD
HEENT: Sclera non-icteric, EOMI, PERRLA. Poor dentition.
NECK: Supple. JVP 10cm.
HEART: RRR, II/VI systolic murmur heard best at the ___.
LUNGS: CTAB. No crackles, wheezing, or ronchi.
ABD: Soft, non-tender, non-distended. Healed abdominal scars.
EXT: 2+ pitting edema in bilateral ___ extending from ankles to
mid shins. No UE pitting edema.
NEURO: AOx3, strength and sensation grossly intact.
Discharge physical exam
=======================
VS: 98.4 134 / 85 74 16 97 97%
GENERAL: NAD
HEENT: Sclera non-icteric, EOMI, PERRLA. Poor dentition.
NECK: Supple. JVP 10cm.
HEART: RRR, II/VI systolic murmur heard best at the LLSB.
LUNGS: CTAB. No crackles, wheezing, or ronchi.
ABD: Soft, non-tender, non-distended. Healed abdominal scars.
EXT: 1+ pitting edema in bilateral ___ extending from ankles to
mid shins. No UE pitting edema.
NEURO: AOx3, strength and sensation grossly intact.
Pertinent Results:
Admission labs
==============
___ 05:57PM BLOOD WBC-4.4 RBC-2.73* Hgb-8.7* Hct-27.4*
MCV-100* MCH-31.9 MCHC-31.8* RDW-13.6 RDWSD-49.4* Plt ___
___ 05:57PM BLOOD Neuts-50.2 ___ Monos-9.7 Eos-2.3
Baso-0.7 Im ___ AbsNeut-2.22# AbsLymp-1.63 AbsMono-0.43
AbsEos-0.10 AbsBaso-0.03
___ 05:57PM BLOOD Glucose-81 UreaN-13 Creat-0.5 Na-143
K-3.7 Cl-109* HCO3-22 AnGap-12
___ 05:57PM BLOOD Albumin-3.2*
___ 05:57PM BLOOD cTropnT-<0.01 proBNP-419*
___ 05:57PM BLOOD ALT-14 AST-17 AlkPhos-109* TotBili-0.2
Discharge labs
==============
___ 09:03AM BLOOD WBC-5.1 RBC-3.16* Hgb-10.0* Hct-31.9*
MCV-101* MCH-31.6 MCHC-31.3* RDW-13.9 RDWSD-51.6* Plt ___
___ 09:03AM BLOOD ___ PTT-28.9 ___
___ 05:54AM BLOOD Glucose-90 UreaN-23* Creat-0.7 Na-141
K-4.8 Cl-108 HCO3-25 AnGap-8*
___ 05:54AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.1
Micro
=====
___ 1:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Imaging
=======
CXR ___
No evidence of pneumonia or pulmonary edema.
Abd US ___. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded
on the basis of this examination.
2. Patent portal vein.
3. Small pneumobilia is similar to ___.
LENIs ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Brief Hospital Course:
Ms. ___ is a ___ y/o F with PMhx of OSA (on CPAP),
fibromyalgia, obesity (s/p RNYGB ___ c/b afferent limb
obstruction s/p subtotal gastrectomy and small bowel resection
now with short gut syndrome (on TPN ___ years), p/w increasing
lower extremity edema and shortness of breath over the last 2
weeks with recent discharge for similar symptoms that had
resolved.
# Dyspnea on exertion/Lower extremity edema:
#Chronic protein calorie malnutrition secondary to short gut:
Likely multifactorial due to chronic malnutrition, anemia, and
deconditioning. Presumed to be related to malnutrition during
last visit, but patient presenting again with same symptoms
despite being on TPN for >2 weeks. Symptoms improved after
gentle diuresis. Heart failure less likely to cause the
presentation given that her echo and stress test were normal a
month ago at ___, not concerning for reduced EF, diastolic
dysfunction or ischemic changes. Clinically, her presentation is
no concerning for PE since she is breathing comfortably at rest
and is satting 100% on room air. She was in normal sinus rhythm,
not tachycardic, and has no evidence of ischemia. We feel that
her edema is most like related to chronic malnutrition which is
persistent from her previous presentation. We will discharge on
Lasix 10mg PO PRN for dyspnea/swelling and the patient will
continue on home TPN for protein-calorie malnutrition and will
follow up with her PCP on ___.
# HTN - Started on captopril 6.25mg TID, which she will
continue. We discussed switching to lisinopril but given her
response to captopril and concerns with the ability to absorb
lisinopril effectively, will remain on captopril for now.
# tooth pain - patient had tooth loss and plans for extraction
in
the near future. This improved with gave viscous lidocaine. The
patient has plan to tooth extraction at ___ in a couple of
weeks.
CHRONIC ISSUES:
===============
# Fibromyalgia: continued home tizanidine
# H/O opiate use: continued home buprenorphine 10mg SL
# OSA: continued home CPAP at night
# Anxiety/depression: continued home mirtazapine
# Agarophobia: continued home lorazepam
# Nausea: continued home Zofran PRN
# Insomnia: continued home Zolpidem
Transitional issues:
==================================
[] New medications: Captopril, Lasix 10 mg prn swelling
[] Monitor for worsening leg edema and encourage using Lasix.
[] The patient has plan to tooth extraction at ___ in a couple
of weeks.
[] will resume TPN at home, TPN orders faxed to infusion company
prior to d/c
[] In 14 days post discharge (___) please check Zn and Cu
levels
#CODE: DNR/DNI
#CONTACT:
- Next of Kin: ___
- Relationship: WIFE
- Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine 10 mg PO QAM:PRN allergies
2. LORazepam 1 mg PO Q8H:PRN anxiety
3. Mirtazapine 30 mg PO QHS
4. Ondansetron 4 mg PO Q4H nausea
5. Tizanidine 4 mg PO Q8H:PRN muscle spasms
6. Zolpidem Tartrate 10 mg PO QHS
7. Ascorbic Acid ___ mg PO BID
8. Buprenorphine 10 mg SL DAILY
9. Calcium Carbonate 500 mg PO BID
10. FoLIC Acid 1 mg IV Q24H
11. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Captopril 6.25 mg PO TID
RX *captopril 12.5 mg 0.5 (One half) tablet(s) by mouth three
times per day Disp #*45 Tablet Refills:*0
2. Furosemide 10 mg PO DAILY:PRN swelling/shortness of breath
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily as
needed Disp #*30 Tablet Refills:*0
3. Ondansetron 4 mg IV TID:PRN nausea
for TPN mix
RX *ondansetron HCl 2 mg/mL 4 mg IV q8 hrs Disp #*10 Vial
Refills:*0
4. Promethazine 6.25 mg IV Q8H:PRN nausea
for TPN mix
RX *promethazine 25 mg/mL 6.25 mg IV q8hrs Disp #*30 Ampule
Refills:*0
5. Ascorbic Acid ___ mg PO BID
6. Buprenorphine 10 mg SL DAILY
7. Calcium Carbonate 500 mg PO BID
8. Cetirizine 10 mg PO QAM:PRN allergies
9. FoLIC Acid 1 mg IV Q24H
10. LORazepam 1 mg PO Q8H:PRN anxiety
RX *lorazepam 1 mg 1 mg by mouth Q8hrs Disp #*90 Tablet
Refills:*0
11. Mirtazapine 30 mg PO QHS
RX *mirtazapine 30 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
12. Ondansetron 4 mg PO Q4H nausea
13. Tizanidine 4 mg PO Q8H:PRN muscle spasms
RX *tizanidine 4 mg 1 capsule(s) by mouth Q8Hrs Disp #*90
Capsule Refills:*1
14. Vitamin D 800 UNIT PO DAILY
15. Zolpidem Tartrate 10 mg PO QHS
RX *zolpidem 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Protein-calorie malnutrition, steatohepatosis,
peripheral edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you had leg swelling and
shortness of breath. We ruled out a DVT in your leg with a
Doppler ultrasound, and got an abdominal US showing fatty liver.
We gave you IV diuretics and started on captopril 6.25 TID for
high blood pressure. We think your swelling has to do with poor
nutrition. You will need to continue on your TPN at home. Also,
please have your Zn and Cu levels checked in 2 weeks on ___.
We wish you all the best.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10417172-DS-18 | 10,417,172 | 28,754,500 | DS | 18 | 2163-05-03 00:00:00 | 2163-05-03 13:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Tetanus Vaccines and Toxoid / amlodipine
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC:Abdominal Pain
.
HPI: Ms. ___ is a ___ y/o F with PMhx of OSA (on CPAP),
fibromyalgia, obesity (s/p RNYGB ___ c/b afferent limb
obstruction s/p subtotal gastrectomy and small bowel resection
now with short gut syndrome (on TPN ___ years), with two recent
admissions for lower extremity edema who presents for abdominal
pain.
She states the pain began suddenly two days ago. She had been in
her normal state of health when she began to have a sharp ___
RUQ and midepigastric abdominal pain. The pain is described as a
burning which was worse with walking and eating. Shortly after
onset she vomited undigested food which she thought was several
days old. This is very abnormal for her as usually, given short
gut syndrome, will have a bowel movement of most food contents 6
hours after eating. The pain became worse and she presented to
the ED.
She denies any sick contacts, endorses low grade temps, denies
any prior episodes like this. She has been on TPN and denies
poor
intake or missing tpn.
In the ED vitals were T 99.7, HR 76, BP 113/74, RR20, O2Sat 99%
RA. Her labs were unremarkable with WBC 6.7, Cr 0.6. She had a
CT
scan which was negative for anastomotic leak or SBO but did show
enteritis. She was seen by the bariatric surgery team who felt
there was no surgical intervention needed and she was admitted
to
medicine for further care. She received several doses of
morphine
and Zofran.
On arrival to the floor she is tearful and having RUQ pain and
nausea. She is fatigued after being in the ED for >36 hrs. She
also endorses ongoing small volume lower extremity edema.
14 point ROS reviewed with patient and negative except per HPI.
.
Past Medical History:
- Obesity (s/p Roux-en-Y gastric bypass c/b afferent limb
obstruction now s/p multiple stomach and small bowel resections
and short gut syndrome)
- History of UE DVT/PE x2 (___) related to PICC line. On
Lovenox until ___.
- OSA on CPAP
- Depression
- Agarophobia
- Fibromyalgia
- Insomnia
Social History:
___
Family History:
Non-contributory
Physical Exam:
DISCHARGE EXAM:
GEN: laying in bed, appears chronically ill but in NAD
HEENT: Poor dentition, slightly dry mucous membranes, EOMI
CV: Regular rate and rhythm
PULM: CABL no wheezing
ABD: Nondistended, diffusely tender in the upper abdomen most
over RUQ, no guarding or rebound tenderness. Multiple
Well-healed
abdominal incisions
MSK: Warm, well perfused, trace extremity edema
Right Arm PICC in place, c/d/i
NEURO: CII-XII grossly intact
SKIN: No rashes
PSYCH: Appropriate mood and affect
GU: no catheter in place
Pertinent Results:
ADMISSION LABS:
===============
___ 05:29PM ___ PTT-28.3 ___
___ 05:29PM PLT COUNT-275
___ 05:29PM NEUTS-65.7 ___ MONOS-9.4 EOS-1.3
BASOS-0.3 IM ___ AbsNeut-4.39# AbsLymp-1.53 AbsMono-0.63
AbsEos-0.09 AbsBaso-0.02
___ 05:29PM URINE UHOLD-HOLD
___ 05:29PM URINE UHOLD-HOLD
___ 05:29PM URINE HOURS-RANDOM
DISCHARGE LABS:
===============
___ 06:09AM BLOOD WBC-5.3 RBC-2.86* Hgb-8.6* Hct-27.5*
MCV-96 MCH-30.1 MCHC-31.3* RDW-13.2 RDWSD-46.9* Plt ___
___ 06:10AM BLOOD ALT-12 AST-12 AlkPhos-88 TotBili-<0.2
___ 06:09AM BLOOD Calcium-8.0* Phos-5.0* Mg-2.1
___ 03:28AM BLOOD CRP-1.1
___ 06:21AM BLOOD Triglyc-36
IMAGING:
========
CT abdomen and pelvis with contrast ___:
1. No evidence of small-bowel obstruction or anastomotic leak,
as clinically
questioned. No free air or free fluid.
2. Mild wall thickening of the proximal jejunum in the right
upper quadrant,
concerning for enteritis.
3. Moderate distention of the urinary bladder. Correlate with
ability to
voluntarily urinate.
KUB ___:
No radiographic evidence of ileus, obstruction, or free air.
KUB ___:
Nonobstructive, nonspecific bowel gas pattern.
CT a/p ___:
1. No acute intra-abdominal pathology is identified. Previously
noted jejunal enteritis has resolved.
Brief Hospital Course:
Assessment and Plan:
Ms. ___ is a ___ y/o F with PMhx of OSA (on CPAP),
fibromyalgia, obesity (s/p RNYGB ___ c/b afferent limb
obstruction s/p subtotal gastrectomy and small bowel resection
now with short gut syndrome (on TPN ___ years), p/w abdominal
pain
found to have enteritis and possible partial SBO.
Acute problems:
#Enteritis
#Partial SBO
Pt presenting with acute onset abdominal pain and low grade
temps at home. Could be consistent with viral gastroenteritis.
Stool studies were checked and were largely unrevealing. CT a/p
showed possible small bowel enteritis but no other acute
findings. Her lactate is negative making ischemic enteritis
less likely. Considered inflammatory bowel disease but CRP is
not elevated and this would be atypical presentation. Bariatric
surgery evaluated her and did not feel this was a
complication from know gastric bypass. GI saw her and felt this
could possibly be partial SBO. She was treated with bowel rest,
IV morphine and prn anti-emetics. Her abdominal pain improved
after a few days but she was still having intractable nausea and
dry heaves which improved after pt was taken off IV morphine and
restarted on home subutext. She felt that both her pain and
nausea were better controlled with this and was tolerating some
PO on day of discharge with plans to ocntinue home TPN.
# Fibromyalgia: continued home tizanidine
# H/O opiate use: held home buprenorphine 10mg SL
# OSA: continued home CPAP at night
# Anxiety/depression: continued home mirtazapine
# Agarophobia: continued home lorazepam
# Nausea: continued home Zofran PRN
# Insomnia: continued home Zolpidem
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO BID
2. Cetirizine 10 mg PO QAM:PRN allergies
3. LORazepam 1 mg PO Q8H:PRN anxiety
4. Mirtazapine 30 mg PO QHS
5. Tizanidine 4 mg PO Q8H:PRN muscle spasms
6. Vitamin D 800 UNIT PO DAILY
7. Zolpidem Tartrate 10 mg PO QHS
8. Ondansetron 4 mg PO Q4H nausea
9. FoLIC Acid 1 mg IV Q24H
10. Ascorbic Acid ___ mg PO BID
11. Captopril 6.25 mg PO TID
12. Furosemide 10 mg PO DAILY:PRN swelling/shortness of breath
13. Ondansetron 4 mg IV TID:PRN nausea
14. Promethazine 6.25 mg IV Q8H:PRN nausea
15. Buprenorphine 20 mg SL DAILY
Discharge Medications:
1. Promethazine 6.25 mg IV Q8H:PRN nausea
2. Ascorbic Acid ___ mg PO BID
3. Buprenorphine 20 mg SL DAILY
4. Calcium Carbonate 500 mg PO BID
5. Captopril 6.25 mg PO TID
6. Cetirizine 10 mg PO QAM:PRN allergies
7. FoLIC Acid 1 mg IV Q24H
8. Furosemide 10 mg PO DAILY:PRN swelling/shortness of breath
9. LORazepam 1 mg PO Q8H:PRN anxiety
10. Mirtazapine 30 mg PO QHS
11. Ondansetron 4 mg PO Q4H nausea
12. Ondansetron 4 mg IV TID:PRN nausea
13. Tizanidine 4 mg PO Q8H:PRN muscle spasms
14. Vitamin D 800 UNIT PO DAILY
15. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel enteritis
possible partial SBO
Short gut syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted after ___ began having abdominal pain. ___ had
a CT scan which was read as enteritis. ___ were seen by the
bariatric surgery team and they felt this pain was not related
to your bypass and gastrectomy. ___ were seen by the
gastroenterologist who thought your symptoms might be secondary
to partial bowel obstruction. ___ were treated with IV pain
medications, IV anti nausea medications and with this your
symptoms improved.
Please return if ___ are unable to control your abdominal pain
at home, if ___ have intractable nausea, vomiting, or if ___
have any other concern.
It was a pleasure caring for ___,
Your ___ Team
Followup Instructions:
___
|
10417172-DS-20 | 10,417,172 | 20,954,707 | DS | 20 | 2163-08-15 00:00:00 | 2163-08-15 20:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Tetanus Vaccines and Toxoid / amlodipine / kaabiven
Attending: ___.
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with complex history including
chronic abdominal pain/nausea due to complications from failed
Roux-en-Y gastric bypass, short gut syndrome on TPN, HTN,
anxiety, and depression who is presenting with acute onset
exertional chest pain. At 2pm after climbing stairs she
experienced stabbing chest pain in the right sternal border that
radiated to the left, left jaw and left arm. The pain improved
when she sat down but has remained a constant pressure and
discomfort. She had an emesis event during the episode and was
dyspneic but states that she is chronically nauseous and
dyspenic. She states that last week she was fighting an upper
respiratory infection but denies any recent fevers, chills,
diarrhea, abdominal pain, new back pain, UTI symptoms, rashes or
difficulty ambulating. She denies recent travel, estrogen
products or cancer history or leg swelling.
Of note, patient had a recent admission to ___ ___ for
Coag
neg staph and strep bacteremia secondary to tunneled TPN s/p 2
week treatment IV vancomycin (last day ___. TTE and TEE w/o
vegetations. Tunneled line placed by ___ ___.
In the ED, initial VS were: T97.8 HR66 BP164/92 RR18 98%RA; Tmax
99.5
Exam notable for: AAOx3, CTAB, RRR no murmurs, chest wall left
port w/o erythema/tenderness; mild left sternal border TTP, abd
diffusely tender +BS
ECG: NSR at 64; normal axis; normal intervals; Q waves in I, II,
aVL; 1mm STE in I, II, aVF; TWI in V1-V2; no STE in precordial
leads; unchanged from prior
Labs showed:
- CBC 4.9 H/H 8.2/23.0 MCV 78 Plt 291
- BMP notable for Cr 0.8
- TNT <0.01
Imaging showed CXR w/o acute process
Consults: None
Patient received: IV morphine, IV promethazine, ranitidine,
sucralfate, captopril
Plan was for ED Obvs with nuclear stress testing however patient
declined as stated this almost killed her last time, thus
patient
was admitted for chest pain evaluation.
Transfer VS were: HR66 BP147/73 RR16 98%RA
On arrival to the floor, patient is very angry and frustrated to
be admitted to the hospital. She endorses HPI as above. She
currently reports mild residual bilateral chest pain and thinks
it is "muscular". She also is concerned about a pulmonary
embolism and lung infarct as she reports she has had both of
these before. She has been taking her lovenox BID. She is also
concerned about her heart. She reports a history of prior
stroke
and MI at ___ and ___ but
denies
history of cath. She reports a negative stress test but this
stress test "almost killed her" and she will never undergo a
stress test again. She reports she is still getting over a URI
from two weeks ago and had some coughing but this is improving.
She states she has had no change in her chronic abdominal pain
and nausea. Last bowel movement was brown, yesterday. She says
she has had poor intake over the last two weeks and thinks she
has lost 4 pounds. She states she drinks about ___ fluid oz per
day and uses TPN at home for nutrition. She denies fevers,
chills, melena, hematochezia, urinary frequency or dysuria. No
PND, orthopnea, cough, pleuritic chest pain.
Past Medical History:
- Obesity (s/p Roux-en-Y gastric bypass c/b afferent limb
obstruction now s/p multiple stomach and small bowel resections
and short gut syndrome)
- History of UE DVT/PE x2 (___) related to PICC line. On
Lovenox until ___.
- OSA on CPAP
- Depression
- Agarophobia
- Fibromyalgia
- Insomnia
Social History:
___
Family History:
Adopted
Physical Exam:
=======================
Admission Physical Exam
=======================
VS: 98.9 139 / 86 70 18 98 RA
GENERAL: fatigued female sitting on edge of bed AAOx3 NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, II/VI SEM LUSB without radiation
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
CHEST: right superior portion of anterior sternum tender to
palpation with tenderness in ICS; left tunneled central line
c/d/I no erythema or induration or drainage
ABDOMEN: extensive surgical scars, well healed, diffuse
tenderness to mild palpation, no rebound or guarding, +BS
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, ambulating
independently
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
========================
Discharge Physical Exam
========================
VS: 24 HR Data (last updated ___ @ 738)
Temp: 98.3 (Tm 98.8), BP: 105/65 (105-145/65-86), HR: 64
(55-64), RR: 16 (___), O2 sat: 97% (96-98), O2 delivery: Ra
GENERAL: fatigued female sitting on edge of bed AAOx3 NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, II/VI SEM LUSB without radiation
LUNGS: CTAB, no wheezes, rales, rhonchi, no use of accessory
muscles
CHEST: left tunneled central line c/d/I no erythema or
induration or drainage
ABDOMEN: extensive surgical scars, well healed, diffuse mild
tenderness to mild palpation, no rebound or guarding, +BS
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, ambulating independently
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
===============
Admission Labs
===============
___ 06:04PM BLOOD WBC-4.9 RBC-3.58* Hgb-8.2* Hct-28.0*
MCV-78* MCH-22.9* MCHC-29.3* RDW-18.2* RDWSD-51.8* Plt ___
___ 06:04PM BLOOD Neuts-63.4 ___ Monos-10.1 Eos-1.0
Baso-0.4 Im ___ AbsNeut-3.08 AbsLymp-1.21 AbsMono-0.49
AbsEos-0.05 AbsBaso-0.02
___ 01:58AM BLOOD ___ PTT-31.9 ___
___ 06:04PM BLOOD Glucose-84 UreaN-14 Creat-0.8 Na-140
K-4.2 Cl-104 HCO3-23 AnGap-13
___ 06:04PM BLOOD cTropnT-<0.01
___ 01:58AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-66
___ 01:58AM BLOOD LD(LDH)-196 TotBili-0.2
___ 06:04PM BLOOD Calcium-8.4 Phos-4.1 Mg-1.9
___ 01:58AM BLOOD calTIBC-404 ___ Ferritn-5.1* TRF-311
==================
Imaging/Procedures
==================
___ Chest X-ray
FINDINGS:
PA and lateral views of the chest provided. Left IJ access
central venous
catheter terminates in the upper SVC. Rounded densities
projecting over the
left hemithorax reflect external garment/buttons. Lungs are
clear.
Cardiomediastinal silhouette appears normal. Imaged bony
structures are
intact. Clips the right upper quadrant noted. No free air
below the right
hemidiaphragm.
IMPRESSION:
No acute intrathoracic process.
___ CTA chest
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval resolution of nearly all solid and ground-glass
nodules with
persistence of one 5 mm ground-glass nodule in the left upper
lobe. Although
this could represent apical pleuroparenchymal scarring or
residual
inflammatory process, follow-up CT in 6 months is recommended.
3. Increasing bibasilar atelectasis with hazy ground-glass
attenuation which
may be due to artifact from respiratory motion.
RECOMMENDATION(S): Follow-up evaluation of persistent left
upper lobe
ground-glass nodule in 6 months.
===============
Discharge Labs
===============
___ 04:34AM BLOOD WBC-5.4 RBC-3.59* Hgb-8.2* Hct-28.1*
MCV-78* MCH-22.8* MCHC-29.2* RDW-18.3* RDWSD-51.6* Plt ___
___ 04:34AM BLOOD Glucose-65* UreaN-20 Creat-0.8 Na-142
K-4.7 Cl-107 HCO3-21* AnGap-14
Brief Hospital Course:
================
Patient Summary
================
___ female with complex history including chronic
abdominal pain/nausea due to complications from failed Roux-en-Y
gastric bypass, short gut syndrome on TPN, HTN, Hx DVT/PE on
chronic lovenox, anxiety, and depression who presented with
acute onset exertional chest pain and dyspnea. Patient was ruled
out for ACS with negative troponins and CKMB. She had a CTA
which showed improvement of prior GGO, no PE. Chest pain
resolved on admission. Patient refused further ACS/CAD workup
despite recommendation of cardiac stress test. Patient also with
several week history of dyspnea on exertion. While hospitalized,
did not have observed oxygen desaturations while ambulating (O2
98-100%). She was found to have severe iron deficiency anemia
and was treated with IV ferric gluconate.
=======================================
Acute medical/surgical issues addressed
=======================================
# Chest Pain
Chest pain occurred after climbing stairs with radiation to her
arms and jaw. Risk factors for ACS include HTN only. However,
did have history of NSTEMI at ___ with mildly
elevated trop and negative cardiac stress test. No early family
history of premature CAD, HLD, DM, or tobacco use. EKG unchanged
from prior although notable for q waves in I, aVL and II. TNT x2
and CKMB negative. ACS ruled out with negative trops. CTA showed
resolution of most of prior GGO, no PE which is improved from
prior study which showed scattered GGOs. Unlikely GI related
pain given character and association with exertion. Likely chest
wall pain syndrome in context of recent URI and coughing or
chostochondritis. Recommended cardiac stress test which patient
declined as it was not within her goals of care.
# Acute on Chronic Dyspnea
Reports dyspnea after climbing stairs which also lead to chest
pain as above. Dyspnea is chronic and likely multifactorial
secondary to resolving URI, anemia, deconditioning, anxiety.
Pulmonary embolism was ruled out with CTA. No history of heart
failure and patient appears euvolemic on exam. Last ECHO
___. VSS stable with unremarkable CXR and patient is not
hypoxemic at rest or with ambulation (ambulatory sat 98-100% on
RA).
# Severe iron deficiency anemia
# Microcytic, hypochromic anemia
# Clean based ulcer at anastomosis
Patient was diagnosed with ulcer at anastamosis on last
admission ___ with EGD. This is likely source of iron
deficiency anemia. No melena, hematochezia and H/H is stable
from baseline. However, now with new microcytic anemia this
admission was previously normocytic. Iron studies showed severe
iron deficiency. Patient reportedly with recent colonoscopy
without colon cancer or polyps. Suspect this is iron deficiency
anemia related to poor absorption in setting of short gut
syndrome and mild GI losses from known anastomotic ulcer.
Received IV ferric gluconate x 2 prior to discharge.
# Chronic Abdominal Pain, Stable
# Chronic Nausea
# Hx Roux-en-Y gastric bypass
History of chronic abdominal pain secondary to multiple
abdominal surgeries. She was previously treated with Fentanyl TD
but transitioned to subutex ___. ___ evaluated and no
concerning refill history. Continued home pain and nausea
regimen
# Hx of PE/DVT
Patient on lovenox SC 80mg BID in setting of history of two PICC
related upper extremity DVT/PE in ___ and ___. Based on
weight-based dosing for therapeutic PE dosing, patient should be
on 60mg SC BID. Unclear why she is on this increased dose. She
was dosed with lovenox SC 60mg BID while admitted.
# CODE STATUS
Patient expressed her wish to be DNR/DNI. Although she is young,
she is chronically ill. She is a former ICU nurse and has full
understanding and knowledge as to what a code status of DNR/DNI
means. She has capacity to make this decision. She also stated
several times that she is 'palliative' and thus declines many
interventions.
=====================
Transitional Issues
=====================
- Patient will need continued IV iron as outpatient given poor
GI absorption and severe deficiency.
- We still recommend that patient have cardiac stress test if
she is willing to have the test done. Would reassess willingness
as outpatient
- Consider outpatient PFTs as further work up for subjective
dyspnea
- Please address patient's lovenox dose as outpatient. Unclear
reason why patient on 80mg BID dosing as opposed to weight based
dose of 60mg BID, discharged on 60 mg BID
-Follow-up evaluation of persistent left upper lobe ground-glass
nodule in 6 months.
Code: DNR/DNI (confirmed)
Contact: Wife ___ - ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Captopril 6.25 mg PO TID
2. Cetirizine 10 mg PO DAILY
3. LORazepam 1 mg PO Q8H:PRN Anxiety
4. Mirtazapine 30 mg PO QHS
5. Ondansetron 4 mg IV Q8H:PRN Nausea
6. Sucralfate 1 gm PO QID
7. Tizanidine 4 mg PO TID:PRN Muscle spasms
8. Zolpidem Tartrate 10 mg PO QHS
9. Promethazine 12.5 mg IV Q8H:PRN Nausea
10. Ranitidine 150 mg PO BID
11. Enoxaparin Sodium 80 mg SC BID
12. Furosemide 10 mg PO DAILY:PRN Edema
13. Buprenorphine 8 mg SL Q8H
14. Gabapentin 100 mg PO BID
15. rOPINIRole 1 mg PO QPM
Discharge Medications:
1. Enoxaparin Sodium 60 mg SC Q12H
2. Buprenorphine 8 mg SL Q8H
3. Captopril 6.25 mg PO TID
4. Cetirizine 10 mg PO DAILY
5. Furosemide 10 mg PO DAILY:PRN Edema
6. Gabapentin 100 mg PO BID
7. LORazepam 1 mg PO Q8H:PRN Anxiety
8. Mirtazapine 30 mg PO QHS
9. Ondansetron 4 mg IV Q8H:PRN Nausea
10. Promethazine 12.5 mg IV Q8H:PRN Nausea
11. Ranitidine 150 mg PO BID
12. rOPINIRole 1 mg PO QPM
13. Sucralfate 1 gm PO QID
14. Tizanidine 4 mg PO TID:PRN Muscle spasms
15. Zolpidem Tartrate 10 mg PO QHS
16.Resume services
Please resume prior TPN order on discharge
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
=================
Primary Diagnosis
=================
Exertional chest pain
Dyspnea on exertion
===================
Secondary Diagnosis
===================
Iron deficiency anemia
Chronic abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had chest pain and trouble breathing and were admitted for
further testing.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had an EKG and blood tests which showed you were not
having a heart attack. We recommended that you have a stress
test to make sure this pain was not coming from your heart but
you elected not to have the study done.
- You had a scan of your lungs which showed no blood clot that
could be causing your shortness of breath
- You were found to have iron deficiency that was causing your
low blood counts and were given IV iron to replenish your iron
stores
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- We recommend that you have a cardiac stress test to evaluate
for coronary artery disease.
- We recommend that you have a colonoscopy to evaluate for colon
cancer or other possible sources of GI bleeding that could be
causing your iron deficiency and low blood counts
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10417172-DS-22 | 10,417,172 | 28,377,645 | DS | 22 | 2163-10-10 00:00:00 | 2163-11-01 15:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
latex / Tetanus Vaccines and Toxoid / amlodipine / kaabiven
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___:
1. Revision of Roux esophagojejunostomy
2. Removal of bezoar.
___:
Ultrasound guided aspiration of abdominal fluid collection
___:
Successful CT-guided placement of an ___ pigtail catheter
into the superficial abdominal wall fluid collection.
History of Present Illness:
___ with history of Roux-en-Y gastric bypass c/b afferent limb
obstruction requiring multiple stomach and small bowel
resections and short gut syndrome on TPN presenting with one
week of worsening abdominal pain, anorexia and dry heaves. The
patient usually vomits ___ times per week, but over the last
week has been vomiting with more frequency. She last passed
flatus last
night and last bowel movement was yesterday.
Past Medical History:
PMH
- Obesity
- Short gut syndrome
- History of UE DVT/PE x2 (___) related to PICC line
- OSA on CPAP
- Depression
- Agarophobia
- Fibromyalgia
- Insomnia
PSH
Roux-en-Y gastric bypass c/b afferent limb obstruction now s/p
multiple stomach and small bowel resections and short gut
syndrome
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
T 99.8 BP 164/93HR 73 RR 18 SatO2 99% RA
NAD
RRR
CTA bil
Abdomen soft, tender to palpation in upper abdomen, distended
Extremities no edema
Discharge Physical Exam:
VS: T: 98.3 PO BP: 102/63 L Lying HR: 64 RR: 18 O2: 97% Ra
GEN: A+Ox3, NAD
HEENT: atraumatic
PULM: No respiratory distress, breathing comfortably on room air
ABD: soft, non-distended, mildly tender to palpation. No rebound
or guarding. Incision with staples OTA. Old midline ___ drain
site with dry sterile dressing c/d/i
EXT: wwp, no edema b/l
Pertinent Results:
IMAGING:
___: CT Abdomen/Pelvis:
1. Status post gastrectomy and esophagojejunostomy with dilated
proximal small bowel loops and a transition point seen within
the ventral upper abdomen, just to left of midline, likely due
to adhesions. These findings are most compatible with a
high-grade small bowel obstruction.
2. Hepatic steatosis.
___: Abdominal x-ray (supine & erect):
1. Proximal jejunal loop remains markedly distended with
fecalized food
content, the degree of which is comparable to the recent CT.
2. Probable passage of contrast into the right hemicolon as seen
on the
upright radiograph.
___: CXR:
A left subclavian central venous catheter tip projects over the
mid SVC. An enteric tube projects over the stomach. There are
low bilateral lung volumes with mild pulmonary edema. Volume
loss in both lower lobes likely reflect atelectasis. There is no
pneumothorax or large pleural effusion. The size of the cardiac
silhouette is within normal limits.
___: UGI SGL CONTRAST W/ KUB:
There is significantly delayed small bowel transit, likely
secondary to edema and the patient's postoperative status.
Given the lack of passage of contrast from the J-pouch into the
more distal small bowel, it is unclear if the new anastomosis
had been crossed. Within these limitations, no leak was
identified from the opacified portion of the J-pouch/ proximal
small bowel.
___: Portable Abdominal X-ray:
There is significantly delayed small bowel transit, likely
secondary to edema and the patient's postoperative status.
Given the lack of passage of contrast from the J-pouch into the
more distal small bowel, it is unclear if the new anastomosis
had been crossed. Within these limitations, no leak was
identified from the opacified portion of the J-pouch/ proximal
small bowel.
___: Portable Abdominal X-ray:
There has been interval passage of contrast into the slightly
more distal
small bowel loops in the mid abdomen. There is no evidence of
extraluminal contrast to suggest a leak at the most recent,
proximal anastomosis.
___: Temporary Central Line:
Successful placement of a temporary triple lumen catheter via
the right
internal jugular venous approach. The tip of the catheter
terminates in the distal superior vena cava. The catheter is
ready for use.
___: CXR (AP & LAT):
Comparison to ___. Stable bandlike opacity at the
bases of the
right lung. New right central venous access line, the tip
projects over the mid to lower SVC. No complications, notably
no pneumothorax. Stable normal appearance of the cardiac
silhouette.
___: CT Abdomen/Pelvis:
1. 4.7 cm rim enhancing, intra-abdominal fluid collection
underlying the
superior aspect of the midline anterior abdominal wall incision
with
surrounding inflammatory changes concerning for abscess
formation.
2. Mild dilatation with small bowel fecalization of the proximal
small bowel loop adjacent the above-mentioned fluid collection.
However, there is oral contrast material within the colon.
Findings likely represent ileus rather than repeat small-bowel
obstruction.
3. New trace right pleural effusion with associated atelectasis.
Tiny focus of air in the right pleural space.
___: US guided Interventional Radiology Procedure:
Technically challenging and unsuccessful attempt at
ultrasound-guided
placement of a drainage catheter the upper abdominal collection.
2 cc of
serosanguineous fluid was aspirated and sent for microbiology
evaluation.
Drain placement could be attempted under CT guidance if drainage
of the
collection is still desired.
___: CT Interventional Procedure:
Successful CT-guided placement of an ___ pigtail catheter
into the
superficial abdominal wall fluid collection. Samples were sent
for
microbiology evaluation.
LABS:
___ 12:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:49AM LACTATE-1.0
___ 09:45AM GLUCOSE-93 UREA N-21* CREAT-0.7 SODIUM-137
POTASSIUM-5.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-13
___ 09:45AM ALT(SGPT)-58* AST(SGOT)-51* ALK PHOS-165* TOT
BILI-0.5
___ 09:45AM LIPASE-9
___ 09:45AM cTropnT-<0.01
___ 09:45AM ALBUMIN-3.5
___ 09:45AM WBC-10.1* RBC-4.07 HGB-10.2* HCT-33.2* MCV-82
MCH-25.1* MCHC-30.7* RDW-23.8* RDWSD-69.7*
___ 09:45AM NEUTS-83.5* LYMPHS-9.6* MONOS-5.7 EOS-0.6*
BASOS-0.2 IM ___ AbsNeut-8.45* AbsLymp-0.97* AbsMono-0.58
AbsEos-0.06 AbsBaso-0.02
___ 09:45AM PLT COUNT-277
MICROBIOLOGY:
___ 12:27 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 1 S
NITROFURANTOIN-------- 32 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
Brief Hospital Course:
Ms. ___ is a ___ with ___ Roux-en-Y gastric bypass c/b
afferent limb obstruction requiring multiple stomach and small
bowel resections and short gut syndrome on TPN, hx DVT/PE on
home lovenox, who presented who presented to ___ with
adbominal pain and emesis. The patient had a CT abdomen/pelvis
which was concerning for a high grade SBO in the alimentary
limb. OSH reports were obtained. On further imaging review, it
appeared that the CT scan was more indicative of a stricture of
the Roux-en-Y esophagojejunostomy. The patient was clinically
stable and declined NGT placement.
On ___, the patient was taken the operating room and
underwent revision of the Roux esophagojejunostomy and removal
of a bezoar. A NGT was placed. The patient tolerated this
procedure well. After remaining hemodynamically stable in the
PACU, the patient was transferred to the surgical floor. The
Acute Pain Service (APS) was consulted for pain control. The
patient received IV ketamine and a hydromorphone PCA. The
ketamine drip was weaned off and the patient was resumed on her
home buprenorphine. When the patient was tolerating a diet, PCA
dilaudid was d/c'd and the patient received PO dilaudid. Pain
management was transitioned from APS to the chronic pain service
(CPS).
Post-operatively, the patient was started on a heparin drip
while NPO and her home lovenox was held. The patient was
started on TPN. On POD #3, the patient underwent upper GI
swallow study to evaluate for any evidence of anastomotic leak
and no leak was identified from the opacified portion of the
J-pouch/ proximal small bowel. The patient's foley and NGT were
removed.
On POD #5, the patient was started on a regular, soft diet, in
addition to her TPN which she tolerated. Her heparin drip was
d/c'd and she was resumed on her home lovenox. On POD #8, the
patient had a temperature to 101.1. CXR was negative, blood
cultures were sent and urine culture showed enterococcus and she
was started on a 3 day course of ceftriaxone. To further pursue
fever workup, she underwent a CT abdomen/pelvis which revealed a
4.7 cm rim enhancing, intra-abdominal fluid collection
underlying the superior aspect of the midline anterior abdominal
wall.
On ___, the patient underwent US guided Interventional
Radiology drainage and a minimal amount of fluid was obtained
and sent for gram stain. However, better access was needed to
drain the remainder of the fluid collection and she went for CT
guided ___ drainage on ___. 5 cc of blood stained fluid was
aspirated with a sample sent for microbiology evaluation and an
___ Fr ___ drain was left in the collection. This drain was
ultimately removed.
The patient remained alert and oriented throughout
hospitalization. She remained stable from a cardiopulmonary
standpoint; vital signs were routinely monitored. The patient
ambulated frequently and was adherent with pulmonary toilet.
She did report episodes of nausea without emesis which she
reported as being her baseline. At the time of discharge, the
patient was doing well, afebrile with stable vital signs. The
patient continued to receive TPN, tolerating light PO intake,
ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with home infusion
and ___ services. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
2. Enoxaparin Sodium 80 mg SC Q12H
3. Mirtazapine 30 mg PO QHS
4. rOPINIRole 2 mg PO QHS
5. Tizanidine 4 mg PO TID:PRN muscle spasms
6. sucralfate 1 gram oral QID
7. Captopril 12.5 mg PO TID
8. Buprenorphine 8 mg SL TID
9. LORazepam 1 mg PO Q8H:PRN anxiety
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Calcium Carbonate 500 mg PO QID:PRN Heartburn
3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
4. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Wean to q4h, q6h, q8h, q12h, q24h then stop. Patient may request
partial fill.
RX *hydromorphone 4 mg 1 tablet(s) by mouth every 3 (three)
hours Disp #*35 Tablet Refills:*0
5. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 3
Days
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
every twelve (12) hours Disp #*6 Capsule Refills:*0
6. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*1
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Prochlorperazine ___ mg PO Q8H:PRN Nausea
RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth every
eight (8) hours Disp #*6 Tablet Refills:*0
9. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
10. Buprenorphine 8 mg SL TID
11. Captopril 12.5 mg PO TID
12. Enoxaparin Sodium 80 mg SC Q12H
13. LORazepam 1 mg PO Q8H:PRN anxiety
14. Mirtazapine 30 mg PO QHS
15. Ondansetron 8 mg IV Q6H
RX *ondansetron HCl 2 mg/mL 8 mg IV every six (6) hours Disp
#*20 Vial Refills:*0
16. Promethazine 12.5 mg IV Q6H
RX *promethazine 25 mg/mL 0.5 (One half) mL IV every six (6)
hours Disp #*10 Ampule Refills:*0
17. rOPINIRole 2 mg PO QHS
18. sucralfate 1 gram oral QID
19. Tizanidine 4 mg PO TID:PRN muscle spasms
20. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Stricture of Roux-en-Y esophagojejunostomy.
2. Bezoar of Roux-en-Y pouch.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with
abdominal pain, nausea, vomiting, and were found to have a
stricture of your Roux-en-Y esophagojejunostomy. You were also
found to have a bezoar (a concentration of undigested material)
in the Roux-en-Y pouch. You were taken to the operating room
and underwent revision of the Roux esophagojejunostomy and
removal of the bezoar. This procedure went well and you had an
abdominal surgical drain left in place to prevent infection as
well as a nasogastric tube for bowel decompression. You had a
swallow study which confirmed no leak from the surgery site and
the nasogastric tube was removed. You tolerated some food and
liquid by mouth and you continued on TPN. Your surgical drain
was removed.
You later had a fever and lab work and imaging was ordered to
determine the cause. You had a CT scan which showed an
abdominal fluid collection. You underwent drainage of this
collection by Interventional Radiology and had a drain placed.
This drain was ultimately removed as it was not putting out
much. You were also found to have a urinary tract infection
(UTI) and you were treated with an antibiotic called cefazolin.
You later had residual symptoms and a urinalysis concerning for
a UTI and have been started on an antibiotic called Macrobid
(nitrofurantoin) which you will continue at home.
You have had return of bowel function and your pain is now
better controlled. Please continue to wean off the oral
dilaudid at home. You are now ready to be discharged home to
continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10417172-DS-23 | 10,417,172 | 29,884,156 | DS | 23 | 2163-12-19 00:00:00 | 2163-12-19 15:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Tetanus Vaccines and Toxoid / amlodipine / kaabiven
Attending: ___.
Chief Complaint:
Left Flank Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Female with very complex history of around 20 GI
tract surgeries including roux-en-Y with short gut on chronic
TPN who presents with concerns that she has pyelonephritis. The
patient describes the pain as bilateral with more intensity in
the left flank along with her epigastrum at a specific point
which worsens with motion along with dysuria, and several
episodes of diarrhea over the 3 days prior to admission. She
notes her baseline is nausea and vomiting; the patient reports
she was awoken from sleep . The patient denies fever. Her
Roux-En-Y underwent revision on ___ by Dr. ___ it
seems in that operation they revised it with a total gastrectomy
and a direct anastomosis to the esophagus was placed. The
patient does eat for taste and comfort but all nutrition is via
TPN. patient reports the pain in her epigastrum has developed
over the week prior to admission.
In the ___ ED her initial vitals, were 98, 80, 132/70, 20,
95%. She was given 1L of IV fluids along with ondansetron and
promethazine and 2 doses of Zosyn along with 4mg of IV morphine.
She underwent a CT scan of the abdomen which notes new
pneumobilia in the left lobe of the liver. Although this was
felt to most likely be post-operative. The bowel was
unobstructed, and no perinephric stranding was noted.
Past Medical History:
PMH
- Obesity
- Short gut syndrome
- History of UE DVT/PE x2 (___) related to PICC line
- OSA on CPAP
- Depression
- Agorophobia
- Fibromyalgia
- Insomnia
PSH
Roux-en-Y gastric bypass c/b afferent limb obstruction now s/p
multiple stomach and small bowel resections and short gut
syndrome
Social History:
___
Family History:
Patient was adopted so family history unknown
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: %
GEN: NAD, Ill appearing
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
CHEST: CVL Right subclavian
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, +R CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Pertinent Results:
Admission labs:
===============
___ 08:00PM BLOOD WBC-7.6 RBC-3.63* Hgb-10.8* Hct-34.1
MCV-94 MCH-29.8 MCHC-31.7* RDW-12.9 RDWSD-44.3 Plt ___
___ 08:00PM BLOOD Neuts-78.9* Lymphs-14.6* Monos-5.5
Eos-0.4* Baso-0.3 Im ___ AbsNeut-6.01 AbsLymp-1.11*
AbsMono-0.42 AbsEos-0.03* AbsBaso-0.02
___ 08:33PM BLOOD ___ PTT-37.4* ___
___ 08:00PM BLOOD Glucose-133* UreaN-14 Creat-0.7 Na-139
K-3.9 Cl-106 HCO3-21* AnGap-12
___ 08:00PM BLOOD ALT-70* AST-67* AlkPhos-176* TotBili-0.3
___ 08:00PM BLOOD Albumin-3.2*
Notable Labs:
=============
-___ Zinc: pending
-___ CRP 36
-___ ESR 34
-___ Vanc trough: ___ ___: 49
-___ Cholesterol 97
Micro:
===========
-___ UCx: mixed bacterial flora (final)
-___ BCx: Staph epidermidis
-___ BCx: Staph epidermidis
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 2 S
-___ BCx (from CVL): no growth (final)
-___ BCx (from CVL): Staph epidermidis, Staph hominus
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
| STAPHYLOCOCCUS HOMINIS
| |
CLINDAMYCIN----------- R <=0.25 S
ERYTHROMYCIN---------- =>8 R <=0.25 S
GENTAMICIN------------ 4 S <=0.5 S
LEVOFLOXACIN---------- 4 R <=0.12 S
LINEZOLID------------- 2 S
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ 1 S <=0.5 S
-___ BCx (from CVL): Staph epidermidis, other CONS
-___ BCx (peripheral stick): Staph epidermidis
-___ BCx (from CVL): NGTD
-___ BCx (from CVL): GPCs
-___ BCx (from CVL): pending
Imaging:
==============
___ 10:___BD & PELVIS W & W/O CONTRA
IMPRESSION:
1. Patient is status post multiple abdominal operations with
Roux-en-Y esophagojejunostomy and multiple additional areas of
anastomoses within the small bowel. There is no small bowel
obstruction.
2. Pneumobilia in the left lobe of the liver is new compared to
prior, but presumably postoperative in nature.
3. No nephrolithiasis. No definite etiology identified for
right flank pain.
___ MRI L spine:
1. Findings compatible with discitis osteomyelitis at T11-12
without adjacent fluid collection or epidural collection. There
is mild prevertebral phlegmon. No evidence of
discitis/osteomyelitis or epidural collection involving the
lumbar spine. Please note, the entirety of the T11 vertebral
body is not within the field of view of this study nor do axial
T1 postcontrast images extend through the affected levels.
Concurrent thoracic spine MRI does not contain post contrast
imaging due to technical factors.
2. No spinal canal stenosis or neural foraminal narrowing.
___ MRI T spine:
1. Findings compatible with discitis osteomyelitis centered at
anterior T11-12 without definite adjacent fluid collection or
epidural collection.
2. Please note, postcontrast images were not performed
secondary to technical factors.
___ MRCP:
1. Post cholecystectomy, without evidence of a biliary leak.
No biliary dilation.
2. Unremarkable appearance of the liver, without focal hepatic
lesions or abscesses.
Brief Hospital Course:
___ y/o F with very complex history of multiple GI tract
surgeries including roux-en-Y c/b afferent limb obstruction, now
s/p total gastrectomy with short gut on chronic TPN who p/w
worsening thoracic-level back pain and epigastric pain. Found to
have coagulase-negative staph bacteremia.
# CoNS (Staph epidermidis & Staph hominis) bacteremia & sepsis
-she endorsed chills while in ED, Temp was ~100 at that time
-high grade bacteremia, with multiple days of +Cx. Last
positive culture was ___
-ID was consulted
-UCx grew mixed bacterial flora, unlikely source
-TTE without evidence of endocarditis
-TEE without evidence of endocarditits
-suspect her central line is most likely source
-treated w/ vancomycin, goal trough ___, and vancomycin dwells
in central line
-OMFS consulted re: potential that she has dental source for her
bacteremia, Panorex and clinical exam did not reveal significant
infection. Low likelihood this was primary source.
-Decision with consultation with ___, ID to treat
through CVL (poor access and heavy dependence on TPN)
- plan IV Vanco with IV lock/dwell for at least 6 wks (last day
___. Follow up ID.
# Thoracic Back pain, due to:
# T11/12 discitis & osteomyelitis
-continued vancomycin as above
-on home buprenorphine
-breakthrough pain control w/ PO morphine PRN pain, PO
tizanidine PRN spasms
-she can continue with morphine taper at home
# Epigastric pain
-ERCP consulted for pneumobilia and the new epigastric pain
-MRCP done: no acute findings
-ERCP team recs: no invasive intervention
-Pain remained essentially unchanged while maintaining NPO
-Pain slightly worsened by trial of PO, but fairly rapidly
returns to baseline
-Continued home pantoprazole, ranitidine. Added Carafate QID
with good effect.
-Reach out to her surgeon, Dr. ___. No new recs
# Chronic nausea
-continue home regimen of IV Zofran q6h, IV promethazine Q6h
# Hx of roux-en-Y c/b afferent limb obstruction now s/p total
gastrectomy and multiple small bowel resections
# Short Gut Syndrome
- Continued TPN via tunneled line
- ___ Zinc level pending
# Obstructive Sleep Apnea
- Patient is non compliant with her home CPAP
# Chronic DVT/Pulmonary Embolism
- Enoxaparin continued (note dose should be 60 by calculation,
but is on 80mg at home)
# Restless Leg Syndrome
- Ropinirole
# Chronic pain syndrome
# Opioid dependence
- continued home buprenorphine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg IV Q6H:PRN Nausea
2. Mirtazapine 60 mg PO QHS
3. Prochlorperazine 10 mg PO TID:PRN nausea
4. Zolpidem Tartrate 10 mg PO QHS
5. Tizanidine 4 mg PO Q8H:PRN spasm
6. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
7. Ranitidine 150 mg PO DAILY
8. Furosemide 10 mg PO DAILY:PRN edema
9. rOPINIRole 2 mg PO QHS
10. Buprenorphine-Naloxone (8mg-2mg) 2.5 TAB SL DAILY
11. Promethazine 12.5 mg IV Q6H:PRN nausea
12. Cetirizine 10 mg PO DAILY
13. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
2. Morphine Sulfate ___ 15 mg PO Q4H:PRN BREAKTHROUGH PAIN
Duration: 2 Days
RX *morphine 15 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
3. Sucralfate 1 gm PO QID
RX *sucralfate [Carafate] 1 gram/10 mL 1 suspension(s) by mouth
four times a day Refills:*0
4. Vancomycin-Heparin Lock ___SDIR see additional
instructions
RX *vancomycin 100 gram 10 mg IV Daily & PRN Disp #*30 Bag
Refills:*0
5. Vancomycin 1000 mg IV Q 8H
RX *vancomycin 1 gram 1 gm IV every eight (8) hours Disp #*90
Vial Refills:*0
6. Buprenorphine 8 mg SL TID
7. Cetirizine 10 mg PO DAILY
8. Enoxaparin Sodium 80 mg SC Q12H
9. Furosemide 10 mg PO DAILY:PRN edema
10. Mirtazapine 60 mg PO QHS
11. Ondansetron 4 mg IV Q6H:PRN Nausea
12. Pantoprazole 40 mg PO Q12H
13. Prochlorperazine 10 mg PO TID:PRN nausea
14. Promethazine 12.5 mg IV Q6H:PRN nausea
15. Ranitidine 150 mg PO DAILY
16. rOPINIRole 2 mg PO QHS
17. Tizanidine 4 mg PO TID
18. Zolpidem Tartrate 10 mg PO QHS
___
To resume all orders that were in place prior to admission to
hospital.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
# CoNS (Staph epidermidis & Staph hominis) bacteremia & sepsis
# T11/12 discitis & osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a real pleasure looking after you. As you know, you
were admitted with back pain and was found to have bacteremia
(with 2 bacteria Staph epidermidis & Staph hominis) & sepsis
along with evidence of discitis & osteomyelitis at T11/T12.
You were placed on IV vancomycin - with multiple blood cxs
returning positive (with the last one being 6.29). You obtained
TTE/TEE which showed no signs of endocardidis. Panorex (dental
x-ray) was done and you were evaluated by our dental team: there
did not appear to be any signs of dental/periodontal abscess.
The concern was of a central line infection. After much
discussions with our central line expert (___), the
decision was to keep the central line in place and to treat
through it with vancomycin with lock - for at least 6 weeks
___ at least). You will be monitored and followed up by
our ID team - who will determine the duration of the IV abx.
The ___ should have weekly CBC with differential, BUN, Cr,
Vancomycin trough with all results sent to:
ATTN: ___ CLINIC - FAX: ___
Please continue with the TPN (as previously scheduled).
Again, it was a pleasure. We wish you a quick recovery.
Your ___ Team
Followup Instructions:
___
|
10417172-DS-25 | 10,417,172 | 22,085,930 | DS | 25 | 2164-01-31 00:00:00 | 2164-01-31 16:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Tetanus Vaccines and Toxoid / amlodipine / kaabiven
Attending: ___.
Chief Complaint:
back pain and fevers
Major Surgical or Invasive Procedure:
___ guided bone biopsy
History of Present Illness:
___ female with hypercoagulability (not worked up)
on Lovenox, osteomyelitis at T11 with chronic tunneled catheter,
hx of stroke and MI, Roux-en-Y complicated followed by multiple
surgeries and bowel resection/ short gut syndrome and now TPN
dependant for years. Presented to the ED with fever of 100.8
during ___ clinic follow up visit. Patient was discharged from
the
hospital ___ after being treated for T11 osteo/ CONS bacteremia,
and ___ after being treated with central line infection.
Patient
has been getting vanco at home with 6 weeks end date ___ (today)
but unfortunately over the last few days she developed mid back
pain, sharp and continuous, aggravated by movement especially if
she doesn't use her brace, partially improves with pain
medications and rest.
In the ED work up revealed:
1. Progression of destructive T11-T12 endplate changes with
involvement of the disc space, consistent with osteomyelitis and
discitis. No abnormal fluid collection or epidural abscess.
2. No cord signal abnormality or cord compression.
Blood cultures drawn in ED and were negative. No
changes around the central line area or pain, no cough, no
dysuria, no abdominal pain. She has chronic diarrhea due to
short
gut syndrome which hasn't changed. Has chronic nausea and
vomiting which also hasn't changed.
Past Medical History:
- Obesity (s/p Roux-en-Y gastric bypass c/b afferent limb
obstruction now s/p multiple stomach and small bowel resections
and short gut syndrome) now on TPN
- History of UE DVT/PE related to PICC line, chronically on
Lovenox
- Recent admission ___ for central line associated high
grade
CoNS and Strep BSI s/p IV vancomycin x 14 day course
- Microcytic anemia
- EGD ___ clean based ulcer @ anastomotic site
- OSA on CPAP
- Depression
- Agarophobia
- Fibromyalgia
- Insomnia
- HTN
- s/p hysterectomy
- s/p CCY
- s/p appy
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
Admission:
Vitals: afebrile and stable vitals now
GENERAL: Alert and NAD.
EYES: Anicteric, pupils equally round
CV: rrr, systolic and diastolic murmurs, No JVD.
Chest: tunneled catheter left upper chest, no signs of
infection.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored.
GI: Abdomen soft, non-distended, non-tender to palpation.
Multiple old healed laparotomy scars.
SKIN: No rashes or ulcerations noted
EXTREMITIES: no splinter hemorrhage, ___ lesions, ___
nodes noted.
NEURO: Alert, oriented, face asymmetric with right facial drop.
PSYCH: appropriate affect
Discharge:
GENERAL: Alert and NAD. Appears comfortable
EYES: Anicteric, pupils equally round
CV: rrr, systolic and diastolic murmurs, No JVD.
Chest: tunneled catheter left upper chest, no signs of
infection.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored.
GI: Abdomen soft, non-distended, milldy tender to palpation
throughout. Multiple old healed laparotomy scars.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face asymmetric with right facial drop.
PSYCH: appropriate affect
Pertinent Results:
Admission:
___ 06:05AM BLOOD Hgb: 9.6* WBC: 4.5
___ 07:50AM BLOOD WBC: 4.1
___ 06:05AM BLOOD Glucose: 86 UreaN: 13 Creat: 0.7 Na: 144
K: 4.5 Cl: 108 HCO3: 24 AnGap: 12 Phos: 4.7* Calcium: 8.2*
___ 12:30AM BLOOD CRP: 1.9
___ 09:38AM BLOOD Vanco: 15.1
___ 02:02AM BLOOD Lactate: 1.5
___ 12:45AM BLOOD Lactate: 0.9
Discharge:
___ 06:45AM BLOOD WBC-4.0 RBC-2.86* Hgb-8.4* Hct-26.6*
MCV-93 MCH-29.4 MCHC-31.6* RDW-12.9 RDWSD-44.0 Plt ___
___ 06:17AM BLOOD Neuts-47.5 ___ Monos-12.2 Eos-4.8
Baso-0.3 Im ___ AbsNeut-1.68 AbsLymp-1.22 AbsMono-0.43
AbsEos-0.17 AbsBaso-0.01
___ 06:08AM BLOOD ___ PTT-30.5 ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-101* UreaN-16 Creat-0.6 Na-146
K-4.1 Cl-107 HCO3-25 AnGap-14
___ 06:45AM BLOOD ALT-40 AST-23 LD(LDH)-148 AlkPhos-143*
TotBili-<0.2
___ 06:45AM BLOOD Calcium-8.0* Phos-4.5 Mg-2.0
___ 06:45AM BLOOD 25VitD-9*
___ 12:30AM BLOOD CRP-1.9
___ 11:08AM BLOOD HIV Ab-NEG
___ 09:38AM BLOOD Vanco-15.1
___ 02:02AM BLOOD Lactate-1.5
___ 06:46AM BLOOD freeCa-1.09*
___ 06:45AM BLOOD WBC: 4.0 RBC: 2.86* Hgb: 8.4* Hct: 26.6*
MCV: 93 MCH: 29.4 MCHC: 31.6* RDW: 12.9 RDWSD: 44.___
TISSUE (Final ___:
Reported to and read back by ___. ___ (___) @
13:27
___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Blood cultures from ___ NGTD
MRI spine
1. Progression of destructive T11-T12 endplate changes with
involvement of the
disc space, consistent with osteomyelitis and discitis. No
abnormal fluid
collection or epidural abscess.
2. No cord signal abnormality or cord compression.
Brief Hospital Course:
Ms. ___ is a ___ female with the past medical history
of spinal osteomyelitis with coagulase negative staph on vanco
at home per central line, hypercoagulability, and short gut
syndrome on TPN, who presented with fever and back pain, found
to have persistent vertebral osteomyelitis, being discharged on
longer course of vancomycin.
# T11/T12 osteo and discitis: Patient was recently discharged
for this issue on ___. She nearly completed a course of IV
vancomycin for a total of 6 week course (end date ___ but
presented to her ID office and was found to have a fever to
100.8 and newly developed sharp mid-back pain aggravated by
movement. In the ED MRI showed persistent signal abnormality in
T11-12 concerning for ongoing osteomyelitis. She was continued
on vancomycin. She had a bone biopsy which grew rare coag
negative staph. Blood cultures were negative but the ID team who
was consulted wanted to ensure that the tunneled line wasn't
infected so two cultures off each port were sent on the day of
discharge. ID consulted, plan for ___ weeks of vancomycin (end
date some time between ___ and ___ and ID follow up. She will
follow up with Dr. ___ in clinic to determine further course.
She will be discharged home with IV antibiotics and continue
them until Dr. ___ her in ___ clinic. For pain she was
continued on buprenorphine 8 mg SL TID, morphine Sulfate ___ 15
mg PO Q4H:PRN for breakthrough pain.
CHRONIC/STABLE PROBLEMS:
# Roux-en-Y gastric bypass c/b afferent limb obstruction with
short gut syndrome, s/p total gastrectomy and multiple small
bowel resections. Nutrition consulted, continued outpatient TPN,
patient allowed to eat for pleasure
# Chronic nausea:
Continued home anti-emetics
# Hypercoagulability with history of venous and arterial
thrombosis: follows up with hematology. Lovenox initially held
due to bone biopsy but was restarted after the procedure.
Transitional Issues:
=============================
[] Follow up blood cultures drawn off both ports requested by ID
at day of discharge
[] ID to determine future vancomycin course.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine 8 mg SL TID
2. Cetirizine 10 mg PO DAILY
3. Furosemide 10 mg PO DAILY:PRN edema
4. Mirtazapine 60 mg PO QHS
5. Morphine Sulfate ___ 15 mg PO Q4H:PRN BREAKTHROUGH PAIN
6. Pantoprazole 40 mg PO Q12H
7. Prochlorperazine 10 mg PO TID:PRN nausea
8. Promethazine 12.5 mg IV Q6H
9. Ranitidine 150 mg PO DAILY
10. rOPINIRole 2 mg PO QHS
11. Sucralfate 1 gm PO QID
12. Tizanidine 4 mg PO TID
13. Enoxaparin Sodium 80 mg SC Q12H
14. Vancomycin 1250 mg IV Q 12H bacteremia
15. Docusate Sodium 100 mg PO BID
16. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
17. Zolpidem Tartrate 10 mg PO QHS
18. Ondansetron 4 mg IV Q6H
19. 70 mg Other BID
Discharge Medications:
1. Buprenorphine 8 mg SL TID
2. Cetirizine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
5. Furosemide 10 mg PO DAILY:PRN edema
6. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
7. Mirtazapine 60 mg PO QHS
8. Morphine Sulfate ___ 15 mg PO Q4H:PRN BREAKTHROUGH PAIN
9. Ondansetron 4 mg IV Q6H
RX *ondansetron HCl 2 mg/mL 4 mg IV every six (6) hours Disp
#*200 Vial Refills:*0
10. Pantoprazole 40 mg PO Q12H
11. Prochlorperazine 10 mg PO TID:PRN nausea
12. Promethazine 12.5 mg IV Q6H
RX *promethazine 25 mg/mL 12.5 mg IV every six (6) hours Disp
#*100 Ampule Refills:*0
13. Ranitidine 150 mg PO DAILY
14. rOPINIRole 2 mg PO QHS
15. Sucralfate 1 gm PO QID
16. Tizanidine 4 mg PO TID
17. Vancomycin 1250 mg IV Q 12H osteomyelitis
End date ___ or longer depending on ID follow up
RX *vancomycin 500 mg 2.5 vials IV every twelve (12) hours Disp
#*100 Vial Refills:*0
18. Zolpidem Tartrate 10 mg PO QHS
19.TPN
Please Resume all prior TPN orders
20.Flushes
Flush line per protocol
21.Outpatient Lab Work
___ CLINIC - FAX: ___ Attn: Dr. ___
___: WEEKLY: CBC with differential, BUN, Cr, Vancomycin
trough
22.Dressing
IV Clear Dressing 4x4.8 in
1 each dressing change
(weekly and prn)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: vertebral osteomyelitis
Secondary:
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you had ongoing infection of
your spine. We treated you with IV antibiotics (continued the
vancomycin). We did a bone biopsy which showed ongoing
osteomyelitis (infection of the bone). The ID team wanted to
continue your Vancomycin for at least a total of 8 weeks but
they may require longer course like 12 weeks. You will follow up
with the ID team (Dr. ___ as you see below.
We wish you all the best.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10417172-DS-26 | 10,417,172 | 23,652,239 | DS | 26 | 2164-03-19 00:00:00 | 2164-03-18 19:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Tetanus Vaccines and Toxoid / amlodipine / kaabiven /
Penicillins
Attending: ___.
Chief Complaint:
RUQ Abdominal pain
Major Surgical or Invasive Procedure:
endoscopy performed on ___
History of Present Illness:
___ woman with hypercoaguability (on lovenox), RYGB c/b
afferent limb obstruction w/ short gut syndrome (on TPN), and
spinal osteomyelitis (CoNS on vancomycin) who is presenting with
acute on chronic abdominal pain.
In terms of her recently history, in ___ she was admitted for
for acute on chronic abdominal pain, EGD unrevealing, GI
recommended continuing Carafate, pain treated with IV narcotics
and additional buprenorphine and ultimately resolved back to
baseline. In ___ she was admitted with a high grade SBO s/p
revision of Roux esophagojejunostomy and removal of a bezoar.
Her most recent admission was from ___ with fever and
worsening back pain and found to have persistent vertebral OM.
ID
was consulted and her vancomycin course was extended with plan
to
continue through ___. She missed her most recent ID appointment
on ___ due to feeling unwell.
She reports that several days before admission she developed
worsening of her chronic nausea with intermittent dry heaving
and
a new RUQ pain. The pain is "searing" and localized, which is
different from her duller, diffuse chronic pain. The pain is
associated with oral intake (she eats small amounts for
pleasure,
though is TPN dependent for nutrition). Her Tmax at home was
100.0. She denies chills, constipation, diarrhea, urinary
symptoms. No new medications, recent travel, or sick contacts.
No
EtOH or herbal supplements.
ED COURSE
Vitals: T 99.2, HR 96, BP 101/83, RR ___ SpO2 98% on RA
Data: WBC 5.7, ALT 85, AST 76 (new), CT A/P no acute process
Interventions: NS 1L, vancomycin, morphine 4mg IV x4, Zofran,
promethazine, ativan
Course: Failed PO challenge in the ED and so admitted
Past Medical History:
- Obesity (s/p Roux-en-Y gastric bypass c/b afferent limb
obstruction now s/p multiple stomach and small bowel resections
and short gut syndrome) now on TPN
- History of UE DVT/PE related to PICC line, chronically on
Lovenox
- Recent admission ___ for central line associated high
grade
CoNS and Strep BSI s/p IV vancomycin x 14 day course
- Microcytic anemia
- EGD ___ clean based ulcer @ anastomotic site
- OSA on CPAP
- Depression
- Agarophobia
- Fibromyalgia
- Insomnia
- HTN
- s/p hysterectomy
- s/p CCY
- s/p appy
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
DISCHARGE EXAM
___ 0813 Temp: 98.4 PO BP: 108/68 L Lying HR: 64 RR: 18 O2
sat: 95% O2 delivery: RA
GENERAL: Chronically ill appearing woman in no distress
EYES: Anicteric, PERRL
ENT: MMM. No OP lesion, erythema or exudate. poor/absent
dentition. Ears and nose without visible erythema, masses, or
trauma.
CV: Heart regular, no m/g.
RESP: Lungs CTAB no w/r/r. Breathing comfortably
GI: Abdomen soft, multiple well-healed surgical scars. normal
bowel sounds. non-distended. +TTP in RUQ without rebound or
guarding.
GU: No suprapubic ttp or fullness
MSK: Extremities warm without edema. Moves all extremities
SKIN: No rashes or ulcerations noted on examined skin
NEURO: Alert, oriented, face symmetric, speech fluent sensation
to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission labs notable for:
WBC 5.7
Cr 0.8
ALT 85, AST 76, AlkP 193, TB 0.2
Lipase 15
___ 05:45AM BLOOD WBC: 5.3 RBC: 3.54* Hgb: 9.8* Hct: 31.4*
MCV: 89 MCH: 27.7 MCHC: 31.2* RDW: 13.0 RDWSD: 42.___
___ 05:45AM BLOOD Glucose: 103* UreaN: 18 Creat: 0.7 Na:
137
K: 4.8 Cl: 102 HCO3: 26 AnGap: 9*
___ 05:45AM BLOOD ALT: 68* AST: 43* AlkPhos: 175* TotBili:
0.2
___ 06:00AM BLOOD calTIBC: 342 Ferritn: 9.0* TRF: 263
Hepatitis panel unremarkable except for HBsAb positive
indicating
immunity.
CT A/P:
1. No evidence of obstruction or other acute process.
2. Sclerosis and erosions involving the endplates at T10-T11,
likely representing sequela of osteomyelitis better
characterized
on MR from ___.
EKG: NSR, QTc 421 ms
CXR: No infiltrate or edema
Radiology read: Minimal left basal platelike atelectasis.
Central venous catheter terminates in the mid SVC.
ENDOSCOPIC STUDIES:
-EGD ___:
Patient is s/p gastrectomy with no stomach. Anastomosis
visualized, with large anastomotic ulcer
Jejunal mucosa appears normal
Otherwise normal EGD to third part of the duodenum
RUQUS ordered ___, notable for fatty infiltration of liver
Brief Hospital Course:
___ w/ hypercoaguability (on lovenox), RYGB
c/b afferent limb obstruction w/ short gut syndrome (on TPN),
and
spinal osteomyelitis (CoNS on vancomycin) who is presenting with
acute on chronic RUQ abdominal pain plus mild transaminitis of
unclear etiology.
#Acute on Chronic Abdominal Pain
#RUQ Pain
#Mild transaminitis
#Fatty liver disease
___ s/p roux-en-y with short gut syndrome and esoph-jej
anastomosis with known anastomotic ulcer who presented with AoC
abdominal pain w/ food, nausea, mild transaminitis as well as
elevated ALP (more likely ___ osteomyelitis; GGT 22). CT A/P
unrevealing. Hepatitis panel unremarkable. No EtOH. ___ EGD
was negative for ulcers and GI felt her chronic pain was
multifactorial including musculoskeletal component, adhesions,
and issues secondary to gastrectomy. At that time they
recommended possible pain consult and possible TCA.
Per current GI consult, "Potential etiology of her pain is
recurrence or persistent of her anastomotic ulcer or gastritis.
Given the pinpoint tenderness, could also consider neuropathic
pain or local nerve inflammation. She has underlying chronic
abdominal pain which is multifactorial - visceral
hypersensitivity, lack of ability to have gastric
distention, extensive adhesions."
- Trend LFT - normalizing (except for ALP, which may be r/t
osteomyelitis)
- CTA and RUQUS with dopplers unremarkable.
- Continued pain control with home buprenorphine as well as
morphine PO PRN
for severe pain morphine IV PRN breakthrough pain. Adding
lidocaine patch and topical capsacin cream. Consulted chronic
pain service for
possible injection to area.
- Nausea control with home Ondansetron 4 mg IV Q6H ,
Promethazine
12.5 mg IV Q6H, Prochlorperazine 10 mg PO TID:PRN nausea,
LORazepam 0.5 mg PO DAILY:PRN nausea
- Continued home Pantoprazole 40 mg PO Q12H and Ranitidine 150
mg
PO DAILY
- Continued home Sucralfate 1 gm PO QID
- Nutrition c/s for continuation of TPN; order K, Mag and phos
daily
- lidocaine patch not working so trialed capsacin and
gabapentin. The latter improved her abdominal pain so it was
prescribed on discharge
- GI performed EGD on ___ to rule out gastritis vs anastomotic
ulcer; study was unremarkable
#Vertebral Osteomyelitis
Last dose of vancomycin on ___ per ID notes. Currently not
complaining of further back pain.
- Completed vancomycin course on ___
#Hypercoaguability: Enoxaparin Sodium 80 mg SC Q12H
___ Edema: hold home Lasix PRN, no edema currently
#Psych: Mirtazapine 60 mg PO QHS, Zolpidem Tartrate 10 mg PO QHS
#Chronic Pain: rOPINIRole 2 mg PO QHS, Tizanidine 4 mg PO TID
FEN: Regular diet, TPN
OUTSTANDING ISSUES
[] FOLLOW UP WITH GI AND PCP FOR ABDOMINAL PAIN
>45 min spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vancomycin 1250 mg IV Q 12H osteomyelitis
2. Buprenorphine 8 mg SL TID
3. Cetirizine 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
6. Furosemide 10 mg PO DAILY:PRN edema
7. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
8. Mirtazapine 60 mg PO QHS
9. Ondansetron 4 mg IV Q6H
10. Pantoprazole 40 mg PO Q12H
11. Prochlorperazine 10 mg PO TID:PRN nausea
12. Promethazine 12.5 mg IV Q6H
13. Ranitidine 150 mg PO DAILY
14. rOPINIRole 2 mg PO QHS
15. Sucralfate 1 gm PO QID
16. Tizanidine 4 mg PO TID
17. Zolpidem Tartrate 10 mg PO QHS
18. LORazepam 0.5 mg PO DAILY:PRN nausea
Discharge Medications:
1. Capsaicin 0.025% 1 Appl TP TID abd pain
RX *capsaicin 0.025 % apply to area of pain three times daily
Disp #*10 Patch Refills:*10
2. Gabapentin 600 mg PO TID
Please do not take before operating heavy machinery
RX *gabapentin 600 mg 1 tablet(s) by mouth three times daily
Disp #*60 Tablet Refills:*0
3. Buprenorphine 8 mg SL TID
4. Cetirizine 10 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
7. Furosemide 10 mg PO DAILY:PRN edema
8. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
9. LORazepam 0.5 mg PO DAILY:PRN nausea
10. Mirtazapine 60 mg PO QHS
11. Ondansetron 4 mg IV Q6H
12. Pantoprazole 40 mg PO Q12H
13. Prochlorperazine 10 mg PO TID:PRN nausea
14. Promethazine 12.5 mg IV Q6H
15. Ranitidine 150 mg PO DAILY
16. rOPINIRole 2 mg PO QHS
17. Sucralfate 1 gm PO QID
18. Tizanidine 4 mg PO TID
19. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Neuropathic abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with right sided abdominal
tenderness. We treated your pain with gabapentin 600 mg TID
daily. We also performed an upper endoscopy which was
unremarkable.
Please follow up with your primary care doctor once you are
discharged.
Followup Instructions:
___
|
10417172-DS-28 | 10,417,172 | 21,610,606 | DS | 28 | 2164-08-23 00:00:00 | 2164-08-25 23:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Tetanus Vaccines and Toxoid / amlodipine / kaabiven /
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
Patient presents with 24 hours of diffuse cramping abdominal
pain. She states that she ate some rice pudding 24 hours prior
to
admission and that since then she has had worsening abdominal
pain, nausea and vomiting. She says that this has happened
previously when she eats foods because of her short gut syndrome
and once when she had similar symptoms she was found to have a
bowel obstruction. She denies fevers but did have rigors last
night. She tried to treat herself with her home IV Zofran
administered through her central line but this did not improve
her nausea and vomiting. The patient also felt she was
dehydrated
and gave herself one liter of IV fluids. Her last bowel movement
was one day ago and was normal. She denies recent changes to her
bowel habits. She does endorse some pain with urination
yesterday.
Past Medical History:
- Obesity (s/p Roux-en-Y gastric bypass c/b afferent limb
obstruction now s/p multiple stomach and small bowel resections
and short gut syndrome) now on TPN
- History of UE DVT/PE related to ___ line, chronically on
Lovenox
- Recent admission ___ for central line associated high
grade
CoNS and Strep BSI s/p IV vancomycin x 14 day course
- Microcytic anemia
- EGD ___ clean based ulcer @ anastomotic site
- OSA on CPAP
- Depression
- Agarophobia
- Fibromyalgia
- Insomnia
- HTN
- s/p hysterectomy
- s/p CCY
- s/p appy
Social History:
___
Family History:
Adopted, unaware of family history
Physical Exam:
ADMISSION EXAM:
VITAL SIGNS:
99.2 | 129 / 63 R Lying | 46 | 18, 95% Ra
GENERAL: Uncomfortable and anxious appearing.
HEENT: Atraumatic. EOMI. Dry mucous membranes.
NECK: Supple.
CARDIAC: ___ systolic murmur @ LUSB. RRR.
LUNGS: CTAB. Normal WOB.
ABDOMEN: Soft, nondistended. Xiphoid process laterally
displaced.
Multiple laparotomy scars noted. No tenderness to palpation. No
masses or organomegaly.
EXTREMITIES: WWP. 2+ DP pulses.
NEUROLOGIC: A+O x3. CNII-XII intact. Moving all extremities.
DISCHARGE EXAM:
GENERAL: Tired appearing
HEENT: No icterus or injection. MMM.
CARDIAC: RRR, ___ systolic murmur @ LUSB
LUNGS: CTAB. Normal WOB.
ABDOMEN: Soft, non-distended, mild diffuse tenderness, worse in
LUQ, no rebound or guarding. Xyphoid process laterally
displaced.
Multiple laparotomy scars noted.
EXTREMITIES: WWP, no edema
NEUROLOGIC: Alert, oriented, attentive.
PSYCH: Dysphoric mood and affect. Linear thought.
Pertinent Results:
Admission Results:
___ 03:45AM BLOOD WBC-11.5* RBC-4.64 Hgb-13.4 Hct-42.0
MCV-91 MCH-28.9 MCHC-31.9* RDW-15.8* RDWSD-52.1* Plt ___
___ 03:45AM BLOOD Neuts-91.2* Lymphs-6.2* Monos-2.0*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-10.53* AbsLymp-0.71*
AbsMono-0.23 AbsEos-0.00* AbsBaso-0.01
___ 03:45AM BLOOD Plt ___
___ 03:45AM BLOOD ___ PTT-27.8 ___
___ 03:45AM BLOOD Glucose-219* UreaN-15 Creat-0.8 Na-138
K-4.1 Cl-101 HCO3-24 AnGap-13
___ 03:45AM BLOOD ALT-40 AST-26 AlkPhos-208* TotBili-1.0
___ 03:45AM BLOOD Albumin-3.3* Calcium-8.5 Phos-2.5* Mg-2.4
Imaging:
___ Abdominal X Ray ===
FINDINGS:
Supine and upright views of the abdomen pelvis are provided.
Patient is
status post cholecystectomy. Surgical material is noted in the
mid and left upper quadrant in keeping with history of Roux-en-Y
surgery.
Nonobstructive bowel gas pattern with few air fluid levels in
the upright in the left upper quadrant. The caliber of the seen
loops of bowel are normal. Dilated loops of bowel. There is
large amount of stool noted in the right lower quadrant.
IMPRESSION:
Nonobstructive bowel gas pattern with few air-fluid levels in
the left upper quadrant. This could be secondary to very mild
ileus.
___ CT Abdomen and Pelvis w/ Contrast===
1. Status post Roux-en-Y gastric bypass without evidence of an
acute
intra-abdominal process.
2. Hepatic steatosis.
3. Sequela of osteomyelitis at T10-11, similar in appearance to
prior exam.
___ Chest X Ray===
No acute cardiopulmonary abnormality.
___ CT ABD/PELVIS===
1. No acute abdominopelvic pathology.
2. Postsurgical changes from Roux-en-Y gastric bypass and
multiple small
bowel resections. No evidence of obstruction.
___ EGD===
Significant food retention just beyond anastomosis.
___ EGD===
Bezoar in jejunal limb (likely blind limb). Other jejunal limb
was patent. Normal EJ anastomosis.
Brief Hospital Course:
Brief Hospital Course
======================================
Ms. ___ is a ___ ___ retired ___ with a history of RnY gastric
bypass c/b short gut syndrome (on TPN via tunneled central line)
who was admitted for acute on chronic abd pain, nausea, and
vomiting. CT showed no evidence of obstruction or other acute
pathology. EGD showed no ulcers but did reveal a bezoar that
have been contributing to symptoms. Patient gradually improved
and was discharged home at baseline with close f/u.
Active Issues
======================================
#Abdominal Pain:
#Nausea:
#Short gut syndrome:
#Slow Transit:
Patient presented with 24 hours of nausea and vomiting, similar
to prior episodes. CT showed no evidence of obstruction,
infection, or other acute pathology. EGD on ___ demonstrated
large bezoar in jejunal limb, thought to be blind limb, that may
have led to her symptoms. She displayed evidence of slow
transit, with residual fecal matter on CT and retained food at
EJ anastomosis on EGD. Slow transit may be secondary to opioid
use for abdominal pain, and was not treated given patient's
history of short gut syndrome. EGD was also negative for
anastomotic ulcer. Patient's pain was managed with home
buprenorphine and morphine. Nausea was controlled with standing
promethazine and prn ondansetron, prochlorperazine and
lorazepam. By the time of discharge, her pain and nausea had
improved to baseline.
#Hypotension: One episode of hypotension with BP ___.
Patient was asymptomatic and lacked any localizing signs of
infection. Improved with IVF bolus.
#Uncomplicated UTI: Experienced dysuria and urgency. UCx grew
coagulase negative Staph. Started on Bactrim DS BID on ___ for 3
day course.
#Nutrition: Continued on home TPN
#Anxiety: Continued on home mirtazapine and started on zolpidem
10 mg QHS.
#History of DVT: Continued on home Enoxaparin Sodium 80 mg SC
Q12H for history of provoked DVT. Note dose is higher than
standard 1mg/kg due to c/f prior treatment failure. Has
Hematology f/u soon.
#Chronic anemia: Stable this admission. Due to iron infusions as
outpatient.
___ Edema: Home Lasix held, no edema.
Transitional Issues
======================================
- Continue Bactrim DS BID through ___
- No other medication changes made this admission
- Note: patient was recommended to initiate care as outpatient
with gastroenterology but declined at this time.
- GI recommended small bowel follow through to ascertain if
bezoar is in blind limb vs. jejunoileal limb; patient declined
test as inpatient but amenable to doing test as outpatient.
- Has Hematology follow-up scheduled to discuss enoxaparin
dosing and iron infusions for chronic anemia
CONTACT: ___ (Wife) Phone: ___
CODE STATUS: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
2. Enoxaparin Sodium 80 mg SC Q12H
3. Furosemide 10 mg PO DAILY:PRN edema
4. Buprenorphine 8 mg SL TID
5. Cetirizine 10 mg PO DAILY
6. Gabapentin 600 mg PO TID
7. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
8. LORazepam 0.5 mg PO DAILY:PRN nausea
9. Mirtazapine 45 mg PO QHS
10. Ondansetron 4 mg IV Q6H
11. Prochlorperazine 10 mg PO TID:PRN nausea
12. Promethazine 12.5 mg IV Q6H
13. Ranitidine 150 mg PO DAILY
14. rOPINIRole 2 mg PO QHS
15. Tizanidine 4 mg PO TID
16. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tab-cap by mouth every twelve (12) hours Disp #*5 Tablet
Refills:*0
2. Buprenorphine 8 mg SL TID
3. Cetirizine 10 mg PO DAILY
4. Enoxaparin Sodium 80 mg SC Q12H
5. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL
DAILY
6. Furosemide 10 mg PO DAILY:PRN edema
7. Gabapentin 600 mg PO TID
8. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
9. Mirtazapine 45 mg PO QHS
10. Ondansetron 4 mg IV Q6H
11. Prochlorperazine 10 mg PO TID:PRN nausea
12. Promethazine 12.5 mg IV Q6H
13. Ranitidine 150 mg PO DAILY
14. rOPINIRole 2 mg PO QHS
15. Tizanidine 4 mg PO TID prn
16. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute on chronic abdominal pain and nausea
Impaired bowel motility
History of Roux-en-Y gastric bypass and bowel resections
Short gut syndrome on chronic TPN
Chronic pain syndrome on chronic opioid therapy
Uncomplicated UTI
SECONDARY DIAGNOSES:
Anxiety
Insomnia
History of DVT
___ Edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___.
WHY YOU WERE ADMITTED TO THE HOSPITAL:
=======================================
- You were having abdominal pain and vomiting not controlled by
your medicines at home.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
==============================================
- Your symptoms were treated with nausea and pain medicines.
- You had a CT scan that did not show any bowel obstructions.
- You had an endoscopy that showed some retained food and no
ulcers.
- You were started on Bactrim for a UTI.
WHAT YOU NEED TO DO WHEN YOU GO HOME:
======================================
- Please take Bactrim twice a day for total 3 days (take last
dose in the morning on ___
- Please follow up with your primary care doctor on ___ ___.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10417458-DS-7 | 10,417,458 | 22,203,786 | DS | 7 | 2159-11-25 00:00:00 | 2159-11-27 20:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weight gain, orthopnea, PND
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ with h/o CAD s/p CABG x3 with known graft
occlusion and native-vessel PCI and ischemic cardiomyopathy
(LVEF ___ s/p ICD placement who presents with weight gain,
orthopnea, and PND in the setting of recent changes to his
diuretic regimen. He was admitted recently to ___
___ in early ___ for syncope attributed to dehydration,
prompting reduction in lisinopril from 5mg to 2.5mg daily and
torsemide from 20mg bid to 20mg daily. He returned to bid
torsemide dosing soon after discharge due to 3-lb weight gain
and was later instructed to increase torsemide regimen to 40mg
qam and 20mg qpm, without significant improvement. On
presentation to cardiology clinic on the day of admission, he
reported 10-lb weight gain, progressive dyspnea on exertion,
worsening orthopnea, and new PND in association with increasing
abdominal girth and lower extremity edema and productive cough
x1 week. He denies chest pain at rest or on exertion,
nausea/vomiting, or diaphoresis. He similarly denies
fevers/chills/sweats, pleuritic chest pain, or wheeze.
In the ED, initial vitals were as follows: 97.2 77 120/97 18
100% 3L. Admission labs were notable for creatinine of 1.6
consistent with baseline, TnT <0.01, proBNP of 6483, and
hematocrit of 33 consistent with baseline. CXR was interpreted
as notable for mild pulmonary edema. He received 40mg IV
furosemide, with approximately 500cc UOP. He reportedly endorsed
desire to hang himself in the context of severe dyspnea on the
night prior to admission, but indicated that suicidality had
passed; nevertheless, he was assigned a 1:1 sitter. Vital signs
at transfer were as follows: 97.9 63 113/72 13 97% RA.
On arrival to the floor, he reports that he is breathing
comfortably sitting upright in bed. He denies chest pain or
discomfort of any kind. He vehemently denies active suicidal
ideation, acknowledging that he did wish to die when gasping for
air intermittently at home.
Past Medical History:
CAD s/p CABG x3 with known graft occlusions, s/p LCx and OM PCI
Remote left cerebellar infarct
Hypertension/hyperlipidemia
COPD
Depression/anxiety
Noninsulin-dependent diabetes mellitus
BPH
GERD
Social History:
___
Family History:
Father died of premature CAD.
Physical Exam:
ADMISSION
VS: 98.3, 118/52, 62, 20, 100% RA
General: Well-appearing in no acute distress
Neck: JVP difficult to assess due to habitus
CV: RRR, II/VI SM at ___ without radiation
Lungs: Speaking in complete sentences without difficulty,
diffuse crackles and expiratory wheeze, no accessory muscle use
Abdomen: Distended, tympanitic, nontender
GU: Deferred
Ext: 1+ pitting edema to knees bilaterally
Skin: Chronic venous stasis changes
DISCHARGE
VS 97.2 (max 97.8) 128/70 (112-128/48-70) 62 (44-68) 22
(___) 98% RA (94-98% RA)
Weight 97.3kg (214.5lbs) (98.1kg yesterday)
I/O 1290/750 + BRx5 (24H) ___ (since MN)
BG ___ 138 135
General: Well-appearing in no acute distress, sitting in chair
Neck: No appreciable JVD at ~___istant heart sounds
Lungs: Speaking in complete sentences without difficulty, no
accessory muscle use. Lungs CTA b/l.
Abdomen: Nondistended, nontender, +BS
Ext: 1+ pitting edema localized to ankles
Pertinent Results:
ADMISSION
___ 01:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:44PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:44PM PLT COUNT-143*
___ 01:44PM NEUTS-69.7 ___ MONOS-7.4 EOS-1.2
BASOS-0.2
___ 01:44PM WBC-8.0 RBC-3.40* HGB-11.2* HCT-33.0* MCV-97
MCH-32.8* MCHC-33.8 RDW-12.7
___ 01:44PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:44PM URINE HOURS-RANDOM
___ 01:44PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:44PM CALCIUM-9.5 PHOSPHATE-3.1 MAGNESIUM-1.9
___ 01:44PM cTropnT-<0.01 proBNP-6483*
___ 01:44PM estGFR-Using this
___ 01:44PM GLUCOSE-113* UREA N-24* CREAT-1.6* SODIUM-145
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-28 ANION GAP-20
___ 09:05PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-1.9
___ 09:05PM CK-MB-3 cTropnT-0.01
___ 09:05PM CK(CPK)-45*
___ 09:05PM GLUCOSE-115* UREA N-24* CREAT-1.5* SODIUM-140
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
OTHER LABS
___ 01:44PM BLOOD cTropnT-<0.01 proBNP-6483*
___ 09:05PM BLOOD CK-MB-3 cTropnT-0.01
___ 07:35AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:45AM BLOOD CK-MB-2 cTropnT-<0.01
DISCHARGE LABS
___ 08:20AM BLOOD WBC-6.3 RBC-3.59* Hgb-11.6* Hct-35.8*
MCV-100* MCH-32.3* MCHC-32.4 RDW-12.7 Plt ___
___ 08:20AM BLOOD Plt ___
___ 08:20AM BLOOD Glucose-170* UreaN-26* Creat-1.6* Na-141
K-4.5 Cl-102 HCO3-31 AnGap-13
___ 08:20AM BLOOD Calcium-9.7 Phos-2.5* Mg-2.3
IMAGING/STUDIES
CXR ___
FINDINGS: The lungs are well expanded. Cephalization and
pulmonary vascular
congestion is seen. Bibasilar atelectasis seen. Severe
cardiomegaly is seen.
A pacer is seen overlying the left chest with intact leads in
appropriate
position. No large pleural effusion is seen. There is no
pneumothorax.
Sternotomy wires are seen, several of which (___) are
fractured.
IMPRESSION: Mild vascular congestion. Cardiomegaly.
TTE ___
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is an apical left ventricular
aneurysm. There is an inferobasal left ventricular aneurysm.
Overall left ventricular systolic function is severely depressed
(LVEF = 25 %) secondary to extensive severe regional wall motion
abnormalities including akinesis of the posterior wall and apex,
and hypokinesis of the anterior and lateral walls. The estimated
cardiac index is depressed (<2.0L/min/m2). The right ventricular
free wall thickness is normal. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic root
is mildly dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets are severely
thickened/deformed. There is "severe" (low-flow/low-gradient)
aortic valve stenosis (valve area 0.9 cm2). The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate (___) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The tricuspid
regurgitation jet is eccentric and may be underestimated. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
Mr. ___ is an ___ with h/o CAD s/p CABG x3 with known graft
occlusion and native-vessel PCI and ischemic cardiomyopathy
(LVEF ___ s/p ICD placement who presents with weight gain,
orthopnea, and PND in the setting of recent changes to his
diuretic regimen.
ACTIVE DIAGNOSES
#) ACUTE DECOMPENSATED HEART FAILURE: Systolic, EF 25%.
Precipitant is likely recent decrease in diuretic regimen due to
concern for contribution to syncope/orthostasis. No obvious
ischemic insult, with troponin <0.01 on three checks. Diuresis
was undertaken with Lasix 40mg IV for several doses, with
significant improvement in breath sounds and peripheral edema.
Pt was transitioned to torsemide 20mg BID on day prior to
discharge, consistent with his prior home regimen before
attempts to downtitrate diuresis regimen. Other medication
changes included increasing lisinopril from 2.5mg to 5mg daily
and decreasing metoprolol from 100mg to 50mg daily. Dry weight
approximately 213-214 lbs; weight on discharge was 214.5 lbs.
Lungs were without crackles, and peripheral edema was localized
to ankles (as compared to extending up to knees at time of
admission) by the time of discharge.
CHRONIC DIAGNOSES
# HTN: BP remained well controlled. Decreased metoprolol and
increased lisinopril dosages as described above.
# CAD s/p CABG x3 with known graft occlusion and native-vessel
PCI: No acute exacerbation of chronic disease. Troponin <0.01
x 3. Continue home clopidogrel and atorvastatin. Decreased
aspirin to 81mg daily. Continued lisinopril and metoprolol at
modified doses as described above.
# COPD: Although there was initially wheeze on exam, it was
thought to be likely cardiogenic in the absence of significant
productive cough. Wheeze improved with diuresis and was absent
on subsequent days after admission. Continued home tiotropium.
# Depression: Although he acknowledged suicidality in the
setting of extreme dyspnea prior to admission, he later
vehemently denied and active suicidality. He had a 1:1 sitter
initially, which was later discontinued. Continued home
citalopram.
# CKI: Creatinine remained 1.4-1.6 this admission, consistent
with baseline.
# Normocytic anemia: Hematocrit was 33 on admission consistent
with baseline, likely anemia of chronic disease in the setting
of CKI. Iron studies were checked and were normal. Further
work-up as outpatient is recommended (see transitional issues).
# BPH: No acute exacerbation of chronic disease. Continued home
finasteride.
# GERD: No acute exacerbation of chronic disease. Continued
home omeprazole.
TRANSITIONAL ISSUES
#CBC showed anemia as well as thrombocytopenia. Iron studies
were checked and were normal. Consider age-appropriate
screening as outpatient, including evaluation for
myelodysplastic syndrome. No recent colonoscopy found in
electronic medical record (though patient had referral for
colonoscopy in ___.
#Cardiac rehab as outpatient - pt will require referral from
outpatient provider
___ failure: Pt will have labs drawn soon after discharge, to
be followed up by outpatient cardiologist's office, to assess
renal function and electrolytes. Torsemide and metoprolol
dosages should be further titrated as outpatient.
#CAD: Aspirin was reduced from 325 to 81mg daily this admission
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 20 mg PO BID
2. Citalopram 10 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. Potassium Chloride 20 mEq PO DAILY
6. GlipiZIDE 5 mg PO DAILY
7. Atorvastatin 40 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Lorazepam 0.5 mg PO BID:PRN anxiety
11. Finasteride 5 mg PO DAILY
12. Nitroglycerin SL 0.3 mg SL PRN pain
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
2. Atorvastatin 40 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
7. Omeprazole 20 mg PO BID
8. Tiotropium Bromide 1 CAP IH DAILY
9. Torsemide 20 mg PO BID
10. GlipiZIDE 5 mg PO DAILY
11. Lorazepam 0.5 mg PO BID:PRN anxiety
12. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*14 Tablet Refills:*0
13. Nitroglycerin SL 0.3 mg SL PRN pain
14. Potassium Chloride 20 mEq PO DAILY
Hold for K >5
15. Outpatient Lab Work
Congestive heart failure, ICD-9 428.0
Please check chemistry 10-panel on ___ prior to
appointment with Heart Failure nurse practitioner.
Send result to: ___, phone ___, fax
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute on chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care at ___
___. As you know, you came to the hospital
with worsening shortness of breath, including shortness of
breath when you were trying to sleep, and weight gain. You were
found to have an exacerbation of your chronic heart failure, and
you received medication to help you get rid of excess fluid in
your body. Your urine output increased, and your breathing
improved.
Please weigh yourself daily and notify your doctor if your
weight goes up by three pounds or more in a day.
Please see the attached sheet for changes to your medications.
We wish you the best in the recovery process.
Followup Instructions:
___
|
10417530-DS-2 | 10,417,530 | 22,574,967 | DS | 2 | 2134-01-22 00:00:00 | 2134-01-22 17:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left neck pain
Major Surgical or Invasive Procedure:
-Left parapharyngeal abcess incision and drainage
-Upper endoscopy
History of Present Illness:
___ with copd, afib on coumadin presents from outside hospital
due to parapharyngeal abscess on the left that is 4 x 1 x 1 cm.
Patient presented with 2 days of increasing sore throat. Patient
sore throat was so severe he was unable to take his medication
as prescribed.
Pt presented to CHA. While at the outside hospital patient was
found to be in Atrial fib with rapid ventricular rate due to not
taking his medication was given IV diltiazem which controlled
his heart rate and started on a dilt gtt. Pt noted to have
trismus and so taken for CT of neck. Patient's CT scan
demonstrated a parapharyngeal abscess on the left measuring
4x1.1x1 cm and also concerns for epiglottitis. Patient was given
IV clindamycin (600mg) and Decadron (10mg) prior to transfer.
Patient was evaluated by ENT who evaluated patient and
determined that there is no signs of epiglottitis. Patient was
transferred here for further evaluation and treatment.
In the ED, initial vitals: 98.5 100 137/75 18 94% ra
- Exam: trimus present, tongue deviated to R, no stridor per
report
- Labs were notable for: WBC 10.9 (91%N), INR 3.6, lactate 1.3
- Bl cx collected
- ENT consulted and did an endoscopic exam which showed L
paraphyngeal fullness from OP down to level of the larynx; also
mild postcricoid edema on the L with slight hooding of the
posterior L TVF; ENT recs included Clinda, MICU admission,
throat swab for culture, 8mg of dex x1 8hrs after first dose at
OSH, NPO
- Imaging not done
- Patient was given: dex (___) and clinda (900 IV) and continued
on a dilt gtt
- ENT felt airway ok for now and intubation not required
- Pt admitted to MICU for airway monitoring given ENT plan for
medical mgmt of parapharyngeal abscess
- Vitals prior to transfer: 97.6 106 142/61 18 94% 4L Nasal
Cannula
On arrival to the MICU, VS were T 98.7, HR 117, BP 143/87, RR
18, SO2 93% on RA. He reported that he continues to experience
odynophagia. He also reports some left ear pain. He denied any
current chest pain, dyspnea, stridor, fevers, chills, n/v.
Past Medical History:
-COPD not requiring home O2
-Afib on warfarin, CHADS2=3 (HTN, age, DM2)
-Hypertension
-Hyperlipidemia
-Type 2 diabetes melitus, on metformin
-PIN III (Prostatic Intraepithelial Neoplasia III)
-PAD (Peripheral Artery Disease) with intermittent claudication
-Colon Polyps
-Vitamin D Deficiency
-Pacemaker: St ___ VVI. ___.
-Pseudophakia
-? LV Dysfunction 50% ___
-Anxiety
-Iron deficiency anemia
-Vitamin B12 deficiency
-Helicobacter pylori serology ab+ in ___, negative stool
antigen ___, unclear if has been treated
Social History:
___
Family History:
No family history of multiple infections.
Physical Exam:
ADMISSION EXAM:
===============
Vitals- T: 98.7 BP: 143/87 P: 120 R: 18 SO2: 95%
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx difficult to assess
2'/2 trismus, tympanic membranes grey and mobile, nasal
turbinates clear
NECK: supple, swelling on the left face submadibular area with
lymphadenopathy, exquistely tender, right side WNL
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Without significant lesions
NEURO: Grossly intact
DISCHARGE EXAM:
===============
Vitals- T:98.4 ___ P: ___ R: 18 O2: 96% RA
I/O since 0:00 360/450
GENERAL: Alert, oriented, no acute distress, sitting calmly in
bed
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly Irregular rate and rhythm, normal S1 S2, no
murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, no clubbing, cyanosis or edema.
SKIN: no rashes or discoloration
NEURO: Full strength in all extremities, grossly assessed to be
normal
Pertinent Results:
ADMISSION LABS: ___
===============
WBC-10.2 RBC-4.64 Hgb-12.9* Hct-41.7 MCV-90 MCH-27.9 MCHC-31.0
RDW-16.7* Plt ___
Neuts-91.1* Lymphs-5.9* Monos-2.1 Eos-0.8 Baso-0.1
___ PTT-55.2* ___
Glucose-176* UreaN-13 Creat-1.0 Na-142 K-4.8 Cl-106 HCO3-21*
AnGap-20
Calcium-8.4 Phos-2.7 Mg-1.7
Type-ART Temp-37.0 pO2-75* pCO2-37 pH-7.43 calTCO2-25 Base XS-0
Intubat-NOT INTUBA
IMAGING:
========
CXR (___): As compared to the previous radiograph, no relevant
change is seen. Normal lung volumes. Borderline size of the
cardiac silhouette with unchanged pacemaker lead. No evidence
of pneumonia, pulmonary edema or pleural effusions.
CT neck ___, CHA): There is prominent left parapharyngeal soft
tissue swelling a longitudinally oriented rim-enhancing fluid
collection measuring 4.0 x 1.1 x 1.0 cm. There is associated
airways narrowing. The epiglottis is thickened and edematous.
The parotid and submandibular glands are normal. There are small
thyroid nodules. The globes and orbits are unremarkable. Is mild
polyploid mucosal thickening or mucous retention cyst in right
maxillary sinus and minimal paranasal sinus mucosal thickening
otherwise. The mastoids are clear. The osseous structures are
intact without destructive lytic or blastic lesion.
Impression: Left parapharyngeal abscess and evidence of
epiglottitis.
EKG (___): AFib with VR of 110, occasional PVC, nml axis, QTc
441, No Q waves, no STD/STE
US LLE (___): 3-cm hematoma in the left medial ankle.
XRAY LLE (___): No acute fracture or dislocation.
___ CT NECK W CONTRAST
No evidence of residual left peritonsillar and parapharyngeal
space abscess, with minimal residual soft tissue prominence,
likely post-operative change, at the site.
___ ESOPHOGRAM
1. No fistula detected.
2. Frank aspiration with thin barium.
___ VIDEO SWALLOW STUDY
1. Laryngeal penetration with thin liquid, nectar thick liquid,
puree, and cookie.
2. Aspiration of thin liquids and nectar thick liquids.
3. Significant functional improvement with chin tuck.
___ CXR
Lungs are clear. There is no pulmonary edema. Cardiomediastinal
and hilar
silhouettes and pulmonary vasculature are normal. No pleural
effusion or
pneumothorax. Right jugular catheter ends in the upper right
atrium.
Transvenous right ventricular pacer lead follows expected
course, from the left pectoral generator, unchanged.
MICROBIOLOGY:
=============
___ Blood Culture, Routine (Final ___: NO GROWTH.
___ R/O Beta Strep Group A (Final ___: NO BETA
STREPTOCOCCUS GROUP A FOUND.
___ THROAT SWAB
SWAB DEEP NECK ABSCESS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT in
this culture..
ANAEROBIC CULTURE (Final ___:
PREVOTELLA SPECIES. SPARSE GROWTH. BETA LACTAMASE
NEGATIVE.
___ PARAPHARYNGEAL ABSCESS:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
___BSCESS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT in
this culture..
ANAEROBIC CULTURE (Final ___:
PREVOTELLA SPECIES. SPARSE GROWTH. BETA LACTAMASE
NEGATIVE.
FLUID CULTURE (Final ___: MIXED BACTERIAL FLORA.
STREPTOCOCCUS ANGINOSUS (___) GROUP. RARE GROWTH.
ANAEROBIC CULTURE (Final ___ SPECIES. BETA
LACTAMASE NEGATIVE. SPARSE GROWTH.
___ C DIFF NEGATIVE
___ MRSA negative
___ H PYLORI
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
POSITIVE BY EIA.
(Reference Range-Negative).
DISCHARGE LABS:
===============
___ 10:35AM BLOOD WBC-5.2 RBC-3.28* Hgb-9.8* Hct-29.9*
MCV-91 MCH-29.8 MCHC-32.7 RDW-17.4* Plt ___
___ 10:35AM BLOOD ___
___ 10:35AM BLOOD Glucose-157* UreaN-8 Creat-0.9 Na-139
K-3.4 Cl-104 HCO3-24 AnGap-14
___ 10:35AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.5*
INR:
___ 10:35AM BLOOD ___
___ 10:43AM BLOOD ___ PTT-29.3 ___
___ 03:42AM BLOOD ___ PTT-28.2 ___
___ 03:39AM BLOOD ___ PTT-25.7 ___
___ 07:30PM BLOOD ___ PTT-21.6* ___
Brief Hospital Course:
___ with COPD, Afib on warfarin, HTN, presented from outside
hospital due to left parapharyngeal abscess, complicated by
dysphagia and atrial fibrillation with RVR in the setting of not
being able to swallow rate controlling medications.
# Left parapharyngeal abscess. CT noted prominent left
parapharyngeal soft tissue swelling. Endoscopic exam did not
reveal epiglottitis despite CT findings concerning for swelling
of the epiglottis and airway. No stridor on presentation and no
evidence of airway compromise. He was treated with dexamethasone
and started on clindamycin 600 mg IV. ENT took patient to OR for
drainage of abscess and placement of ___ drain. Cultures
grew streptococcus anginosus and his WBC count became elevated.
He was broadened to vancomycin and piperacillin/tazobactam. ENT
continued to check wound and change dressing twice daily. They
noted ongoing purulent drainage. Dental was consulted to
evaluate for an ongoing intraoral infection as a potential
origin for the parapharyngeal abscess. They found no evidence of
an acute ongoing infection in his mouth. He completed 2-week
course of antibiotics and packing was removed. No further
bleeding or infection. He underwent a CT scan of his neck that
showed resolution of the abscess. A barium swallow study
demonstrated no evidence of a leak, but did confirm ongoing
aspiration.
# Dysphagia. Secondary to left parapharyngeal abscess. The
patient failed his video swallow evaluation on ___. Multiple
attempts with bedside Dobhoff placement failed. Dobhoff was
placed successfully under fluoroscopy ___. Speech and swallow
continued to evaluate patient. He had multiple attempts at NGT
placement at bedside and fluoroscopy without success. He had a
repeat speech and swallow on ___ and was able to tolerate a
modified diet with aspiration precautions. He was able to take
oral medications without difficulty.
# Afib with RVR. Due to RVR in setting of infection and
bleeding, the patient was placed on a diltiazem gtt for rate
control with good effect. He was supratherapeutic with INR 3.6
on admission. His warfarin was held and his INR reversed with
vitamin K in preparation for I&D in the OR. His CHADS2 score was
calculated at 3 (HTN, age, DM) and he has no history of stroke.
Following placement of a Dobhoff tube, he was given oral
diltiazem per NGT following his home dosing regimen. During his
acute GI bleed, he developed RVR again and when transferred to
the ICU, he was again placed on a diltiazem gtt for rate
control. Once pt able to swallow, he was switched on ___ to oral
diltiazem with well controlled HR. On discharge, he was
converted from short-acting diltiazem 90mg PO Q6H back to his
home diltiazem ER 300mg daily.
# Acute blood loss anemia, due to duodenal ulcer. On ___ patient
had multiple episodes of melena with Hct drop from 35 to 21.7
over 2 days. ENT evaluated him and felt bleeding was unlikely to
be from parapharyngeal abscess. He received Kcentra for reversal
of INR, and warfarin was held. He was transferred to the ICU. A
bedside EGD was performed which showed a clean based ulcer in
the duodenum, that was not bleeding, and it was felt to be the
source of his bleeding. Over the course of the next few days,
the patient received 5u pRBCs with stabilization in his
hematocrit. He was treated with a PPI bolus and gtt. H. Pylori
antibody was positive, however after discussion with his PCP's
office, he had positive serology in ___, negative stool
antigen in ___, but no record of pt being treated. Since
we could not reach PCP to clarify, we did not start antibiotics.
We will email PCP and defer treatment decision to PCP given
clinical stability. Warfarin 5mg daily was restarted on the
evening of ___. Given recent bleeding, no history of stroke, and
moderate CHADS2 score, he was not bridged. He was maintained on
heparin SC for DVT prophylaxis in-house. INR was 1.4 on
discharge. INR will need to be checked and warfarin adjusted for
goal INR ___.
# Subacute hematoma of LLE. Patient had two weeks of pain on the
medial aspect of his LLE. On exam, there was noted a prominent
swelling without discoloration or erythema. He had seen his PCP
earlier and was started on gabapentin for concern for a
neuropathic component of this pain. An US of his ___ revealed a
fluid collection most consistent with a subacute hematoma. Our
suspicion is that this formed in the setting of minimal trauma
while supratherapeutic on his warfarin. We discontinued his
gabapentin. Pain and hematoma resolved.
#COPD. Continued ipratropium and albuterol nebs q6 PRN wheeze.
Encouraged incentive spirometer.
#DMII. Held metformin and transitioned to ___ during
hospitalization. Restarted metformin on discharge.
### TRANSITIONAL ISSUES ###
-Monitor INR. Restarted on warfarin 5mg on ___ for goal INR ___.
INR was 1.4 on discharge. No bridging required.
-Aspiration precautions
-H.Pylori serology returned positive, nurse at ___ PCP ___.
___ pt had positive serology in ___,
negative stool antigen in ___, but no record of pt being
treated. Cannot reach PCP to clarify, therefore will not start
antibiotics. Will email and defer treatment decision to PCP
given clinical stability.
-Started pantoprazole for GI bleeding and duodenal ulcer
-Discontinued gabapentin (recently started by PCP ___
?neuropathic pain of LLE, which is actually small hematoma).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. MetFORMIN (Glucophage) 850 mg PO DAILY
4. Warfarin 7.5 mg PO 3X/WEEK (___)
5. Warfarin 10 mg PO 4X/WEEK (___)
6. Tiotropium Bromide 1 CAP IH DAILY
7. Diltiazem Extended-Release 300 mg PO DAILY
8. cilostazol 50 mg oral BID
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
10. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
11. Finasteride 5 mg PO DAILY
12. Terazosin 10 mg PO HS
13. Gabapentin 100 mg PO TID
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Terazosin 10 mg PO HS
5. Senna 8.6 mg PO BID
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. cilostazol 50 mg ORAL BID
8. MetFORMIN (Glucophage) 850 mg PO DAILY
9. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
10. Tiotropium Bromide 1 CAP IH DAILY
11. Warfarin 5 mg PO DAILY16
12. Docusate Sodium 100 mg PO BID
13. Diltiazem Extended-Release 300 mg PO DAILY
14. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Left parapharyngeal abcess
-Atrial fibrillation with rapid ventricular response
-Dysphagia
-Acute blood loss anemia, due to duodenal ulcer
-Positive H. pylori serum antibody
SECONDARY:
-Chronic obstructive pulmonary disease
-Type 2 diabetes mellitus
-Benign prostatic hyperplasia
-Diabetes mellitus
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted with left sided neck pain and
difficulty swallowing. You were found to have an abscess in your
neck. The ENT team brought you to the operating room and opened
the abscess to drain it. You were also given steroids to help
with the inflammation and strong antibiotics to fight the
infection.
We had to place a nasogastric tube through your nose to your
stomach in order to give you your medications while you were
unable to swallow. Most importantly, we needed to give you
diltiazem to slow down your heart rate from atrial fibrillation.
You also had a bleed of the gastrointestinal tract due to a
duodenal ulcer found on endoscopy. You were given blood
transfusions for your blood loss and your blood counts
stabilized.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
10418005-DS-10 | 10,418,005 | 25,388,826 | DS | 10 | 2131-01-18 00:00:00 | 2131-01-16 12:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
Hyperglycemia, lactic acidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with a hx of IIIB(pT3N1a, pMMR,
KRAS WT) left-sided colorectal adenocarcinoma s/p left
hemicolectomy, currently C2D19 FOLFOX adjuvant chemotherapy, DM
type II, and HTN who presents with worsening fatigue, weakness
and dehydration.
The patient has had significant nausea, decreased appetite, and
mild neuropathy in the setting of FOLFOX. She was last seen in
clinic on ___, at which time Dr. ___ a plan for
weekly IV fluids and Zofran, and added dexamethasone 4mg x 4
days to assist with appetite. The patient began having worsening
oral intake over the last two days with progressive weakness.
She received 1L IV fluids on ___. She then called the OMED team
yesterday, who recommended monitoring and encouraged oral
intake. Around ~12 pm today, she had profound weakness,
including inability to stand or walk and changes in her mental
status, prompting the husband to take her to the emergency
department.
In the ED, initial vitals: Temp 98.3 BP 112/79 HR 146 RR 22 98%
on RA
Exam notable for: not documented
Labs notable for: Na 156, HCO3 15, BUN 53, Cr 1.9, AG 36, WBC
3.8, lipase 223, AST 78, trop <0.01, VBG ___
Imaging: CXR negative
Patient received: Given 4L NS, insulin gtt
Consults: None
Vitals on transfer: Temp 97.4 BP 125/82 HR 112 RR 21 100% on RA
Upon arrival to ___, she reports ongoing fatigue and weakness.
She reports one week of increased urinary frequency and dysuria,
no hematuria, abdominal pain or flank pain. Also describes
shortness of breath without chest pain or cough. No headaches,
nausea, vomiting, congestion, rhinorrhea or sore throat.
REVIEW OF SYSTEMS:
(+) Per HPI, otherwise ROS negative
Past Medical History:
Hypertension
Diabetes Mellitus type II
H/o positive PPD, s/p 8 months INH
Uterine fibroids
S/p C-section (___)
Social History:
___
Family History:
Both mother and father are alive. Maternal aunt with breast
cancer. MGF died of unknown cancer. PGF had colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: BP 131/88 HR 128 RR 20 97% on RA
GENERAL: WDWN female in NAD. Lying comfortably in bed. Kept eyes
closed, tired appearing.
HEENT: Sclera anicteric, dry MM, cracked tongue
NECK: Supple
LUNGS: Kussmaul breathing. Clear to auscultation bilaterally, no
wheezes, rales, or rhonchi.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-distended, mild TTP over LLQ, no guarding, bowel
sounds present
GU: No suprapubic or CVA TTP bilaterally.
EXT: Warm, well perfused, 2+ pulses, no ___ edema or erythema.
SKIN: Warm, dry. No rashes.
NEURO: Somnolent though interactive with questioning. Oriented
x4. CN II-XII grossly intact. Moves all extremities.
ACCESS: 2 PIV, port
DISCHARGE PHYSICAL EXAM:
VITALS: 99.9 126 / 81 99 18 98 RA
GEN: NAD, less fatigued appearing
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB
GI: soft, NT, ND, NABS
MSK: No visible joint effusions or deformities.
DERM: No visible rash. No jaundice. Port site appears C/D/I
without any pain or erythema.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: WWP, no edema
Pertinent Results:
ADMISSION LABS:
==============
___ 08:56PM BLOOD WBC-3.8* RBC-5.69* Hgb-15.3 Hct-49.0*
MCV-86 MCH-26.9 MCHC-31.2* RDW-19.9* RDWSD-56.4* Plt ___
___ 08:56PM BLOOD Neuts-68.3 ___ Monos-8.7 Eos-0.0*
Baso-0.3 Im ___ AbsNeut-2.59 AbsLymp-0.83* AbsMono-0.33
AbsEos-0.00* AbsBaso-0.01
___ 08:56PM BLOOD Plt ___
___ 03:30AM BLOOD Plt ___
___ 08:56PM BLOOD Glucose-1193* UreaN-53* Creat-1.9*
Na-156* K-7.8* Cl-104 HCO3-15* AnGap-36*
___ 08:56PM BLOOD ALT-31 AST-78* AlkPhos-97 TotBili-0.4
___ 08:56PM BLOOD Lipase-223*
___ 08:56PM BLOOD Albumin-4.6 Calcium-11.2* Phos-5.9*
Mg-3.7*
___ 10:39PM BLOOD Osmolal-408*
___ 09:03PM BLOOD ___ pO2-77* pCO2-35 pH-7.28*
calTCO2-17* Base XS--9 Intubat-NOT INTUBA
___ 10:56PM BLOOD ___ pO2-30* pCO2-53* pH-7.19*
calTCO2-21 Base XS--9 Intubat-NOT INTUBA
___ 09:03PM BLOOD Glucose->500 Lactate-5.5* Na-162* K-3.9
Cl-113* calHCO3-16*
DISCHARGE LABS:
===============
___ 05:26AM BLOOD WBC-4.7 RBC-3.18* Hgb-8.6* Hct-26.8*
MCV-84 MCH-27.0 MCHC-32.1 RDW-19.2* RDWSD-54.6* Plt ___
___ 05:25AM BLOOD Glucose-111* UreaN-5* Creat-0.6 Na-143
K-4.1 Cl-106 HCO3-26 AnGap-11
___ 05:37AM BLOOD ALT-26 AST-44* LD(LDH)-375* AlkPhos-77
TotBili-0.4
___ 12:36AM BLOOD Lipase-63*
___ 03:30AM BLOOD CK-MB-6 cTropnT-<0.01
___ 05:25AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1
___ 12:36AM BLOOD calTIBC-229* VitB12-691 Folate->20
Hapto-375* Ferritn-254* TRF-176*
___ 12:36AM BLOOD TSH-1.1
___ 05:34AM BLOOD freeCa-1.14
___ 09:40AM BLOOD STRONGYLOIDES ANTIBODY,IGG-***pending***
IMAGING AND STUDIES:
======================
LEFT UE US
1. Nonocclusive thrombus in the left internal jugular vein.
2. An echogenic catheter is noted at the site of the patient's
palpable cord and may represent an unusual course of the
patient's port catheter (as demonstrated on recent radiographs).
If there is persistent clinical concern, CT neck can be
obtained.
RUQUS
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
2. The hepatic segment VI lesion previously identified on the CT
abdomen pelvis dated ___ is not visualized
sonographically. Further evaluation with a contrast enhanced
MRI of the liver is recommended.
CT Abdomen
1. New 15 x 17 x 19 mm hypodense lesion within segment 6 is
indeterminate, with a broad differential which includes
malignancy or infection. Consider US
for further evaluation of solid versus cystic components.
2. No evidence of small or large bowel inflammation.
MRI Brain
No evidence for intracranial metastatic disease or acute
intracranial abnormalities.
MRI liver
There is moderate steatosis of the liver. The hypodense lesion
in segment ___ ___orresponds to an area of increased signal
drop on the out of phase sequence, with lack of enhancement or
correlate on T1 and T2 weighted imaging. This most likely
represents an area of more focal severe fatty infiltration.
Fibroid uterus, incompletely visualized.
Brief Hospital Course:
This is a ___ with colon cancer (stage IIIB, s/p L
hemicolectomy; s/p 2 cycles FOLFOX), DM2 on oral agents, HTN on
chlorthalidone, admitted for DKA/HHS, likely precipitated by
dexamethasone. Also with line-associated L IJ DVT; was on
argatroban while HIT was ruled out, now Lovenox. Main issues
that led to her protracted hospital stay were recalcitrant
nausea/poor PO intake symptoms along with intermittent fevers of
unclear provenance.
# FEVERS: She has had low grade fevers and true fever
intermittently here, some >101. Unclear etiology. Not a classic
side effect of chemotherapy. Basic infectious workup with blood,
urine, chest radiography have been reassuring serially.
Abdominal exam benign and abdominal imaging unremarkable.
Abdominal CT here showed new lesion in liver, infectious/
inflammatory/ neoplastic all possible, but MRI liver was
unrevealing. Possibly related to thrombosis. Given GI symptoms
and her ___ roots/travel, parasitosis studies were sent but
have been unrevealing to date.
- F/u parasitosis studies including Strongy ab
# POOR PO INTAKE
# NAUSEA
# DIARRHEA
# THRUSH
# RISK FOR MALNUTRITION
# HYPOKALEMIA: She reported very poor PO intake with a variety
of symptoms, all of which potentially attributable to
chemotherapy. MRI negative for intracranial metastasis. CT
abdomen without signs of enteritis. C diff negative.
1) No appetite (tried dronabinol and found it sedating), now on
mirtazapine.
2) Dysgeusia (slowly improving)
3) Oral thrush (treating with PO fluconazole 100 mg daily x2
weeks)
4) Esophageal dysphagia when drinking anything cold (which her
oncologist tells me is a common chemo side effect), improving,
on PPI
4) Dyspepsia, improving, on PPI
5) Nausea (standing Zofran and PRN Compazine and Ativan, all of
which she was on before)
6) Lower abdominal cramps worsened by food, briefly on
hyoscyamine, now DCd, resolved
7) Diarrhea, improving
- Continue K repletion standing
- Continue Mg repletion PRN
- Continue every other day IVF for now
- Follow up studies for intestinal parasitosis as above
# DM2 with HYPERGLYCEMIA
# DKA/HHS: Most likely secondary to sugary fluid intake and
dexamethasone, which has been discontinued. She was on an
insulin gtt in the ICU and is now stable on SQ insulin (new) and
metformin. Glipizide started and tolerating. ___ was
originally taking her off glargine but the order remained
active, and her ___ have been great.
- Continue Lantus 10U/day
- Continue low dose Metformin
- Continue glipizide
- Instructed to monitor ___ QAM, more frequently if going up,
and to decrease Lantus dose by 2 units per day/call MDs if ___
are consistently less than 100.
# Line-associated LIJ thrombus: HIT antibody was negative. Was
on argatroban while HIT was ruled out, now Lovenox. Patient was
doubtful she will be able to do Lovenox at home. With consent of
her heme/onc doctor, switched to Eliquis at discharge (given
emerging data for non-inferiority of DOACs in solid tumor
patients).
- Eliquis BID, duration per Heme/Oncologist
# PORT PLACEMENT/MALPOSITIONING: Her port takes an unusual
course, entering the IJ cephalad. Flushes well enough that it is
not kinked. Communicated with Dr ___ by email. He looked at
the images and is fine with its position.
# FATIGUE: Likely multifactorial with chemo, anemia,
malnutrition, hospitalization. ___ evaluated and cleared for
home. Had some improvement with Ritalin dose yesterday. Can
consider uptitration outpatient.
- Continue Ritalin trial
# UNSTEADINESS ON FEET: Likely due to mild hypovolemia,
deconditioning. ___ consulted, recommended home after a couple of
___ visits.
# THROMBOCYTOPENIA (NON-HIT, IMPROVED OVERALL)
# LEUKOPENIA (IMPROVING)
# ACUTE ANEMIA (IMPROVING): Likely a delayed effect of chemo, as
per Onc the typical drop is Plts then RBCs and WBCs and she
dropped Plts and WBCs briefly as well, and all now improving
spontaneously. She is on AC but has been no obvious bleeding and
stool guaiac negative x3. No signs of hemolysis by haptoglobin/
bilirubin. LDH moderately elevated. Few schistos on RBC
morphology. B12/folate sufficient. INR WNL.
# HYPERNATREMIA: Rapid changes in osmolarity during treatment
with insulin gtt and IVF; pt has been intermittently on free
water restriction, and briefly was given hypertonic saline. Na
has now normalized.
# ACUTE KIDNEY INJURY: Most likely due to severe dehydration,
now resolved.
>30 minutes spent coordinating discharge home with services
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H
2. Enoxaparin Sodium 40 mg SC DAILY
3. amLODIPine 5 mg PO DAILY
4. Chlorthalidone 12.5 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Ibuprofen 600 mg PO Q8H:PRN Pain - Severe
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation/hard stool
9. Dronabinol 5 mg PO TID:PRN Nausea
10. Ondansetron 8 mg PO Q8H:PRN Nausea
11. LORazepam 0.5 mg PO Q8H:PRN Nausea
12. Prochlorperazine 10 mg PO Q6H:PRN Nausea
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*3
2. Fluconazole 100 mg PO Q24H Duration: 3 Days
RX *fluconazole 100 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. GlipiZIDE XL 10 mg PO DAILY
RX *glipizide 10 mg 1 tablet(s) by mouth daily in AM Disp #*30
Tablet Refills:*3
4. Glargine 10 Units Breakfast
RX *blood sugar diagnostic Use as directed Four times daily
Disp #*120 Strip Refills:*3
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 10 Units before BKFT; Disp #*10 Syringe Refills:*3
RX *blood-glucose meter Use as directed Disp #*1 Kit
Refills:*0
RX *lancets Use as directed four times daily Disp #*100 Each
Refills:*3
5. MethylPHENIDATE (Ritalin) 5 mg PO QAM
RX *methylphenidate HCl 5 mg 1 tablet(s) by mouth daily in AM
Disp #*30 Tablet Refills:*0
6. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth daily in evening
Disp #*30 Tablet Refills:*3
7. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
8. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
9. Potassium Chloride 60 mEq PO DAILY
RX *potassium chloride 20 mEq 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
10. Acetaminophen 1000 mg PO Q8H
11. LORazepam 0.5 mg PO Q8H:PRN Nausea
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Ondansetron 8 mg PO Q8H:PRN Nausea
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation/hard
stool
15. Prochlorperazine 10 mg PO Q6H:PRN Nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
DKA/HHS
Line-associated DVT
Chemotherapy side effects
Low grade fevers of unclear source
Discharge Condition:
Fatigued, but eating and drinking and slowly improving overall
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were brought to the hospital with DKA/HHS, which is a state
progressively uncontrolled blood sugars and resultant severe
dehydration, which progresses in a vicious cycle until ___
become very, very ill. ___ can prevent this happening again by
good control of your diabetes and maintaining your hydration.
___ were started on insulin, which ___ will need to take in
addition to your metformin, at least for the near future.
___ also had a blood clot at the site of your port-a-cath. ___
will need to take apixaban 5 mg twice daily for as long as ___
have the port, or three months, whichever is longer.
Followup Instructions:
___
|
10418126-DS-10 | 10,418,126 | 27,510,878 | DS | 10 | 2186-03-19 00:00:00 | 2186-03-19 14:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Travatan Z / Combigan / ___ P / Namenda
Attending: ___.
Chief Complaint:
LLE pain
Major Surgical or Invasive Procedure:
L TFN
History of Present Illness:
Ms. ___ is an ___ yo F who presents to ___ ED w/ a left hip
fracture after mechanical fall this evening. Patient states she
was reaching for something on a chair above her head, lost her
balance, and fell on left hip. Positive HS, no LOC, no other
injuries.
She denies any presyncopal symptoms, chest pain, SOB, nausea,
vomiting, diarrhea.
Past Medical History:
DERMATITIS
DYSPEPSIA
GLAUCOMA
HAIR LOSS
HEALTH MAINTENANCE
HYPERTENSION
LEG PAIN
NECK PAIN
OSTEOPOROSIS
Bone Density Study done ___.
RECTAL BLEEDING
RIB PAIN
ANKLE SPRAIN
ACTINIC KERATOSIS
KNEE PAIN
R DISTAL CLAVICLE FX ___
CLAVICLE FRACTURE
Right, due to Fall out of kitchen chair.
TRICUSPID REGURGITATION
FALLS
Family History:
noncontributory
Physical Exam:
Gen: well appearing, no acute distress
CV: RR
Lungs: breathing room air
LLE: incision c/d/I. sgilt s/s/t/dpn/spn. fires ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left intertrochanteric fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left total femoral nail, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the left lower extremity, and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lumigan (bimatoprost) 0.01 % ophthalmic BID
2. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q4H
2. Enoxaparin Sodium 40 mg SC Q12H
Start: ___, First Dose: 1800
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous daily--6 pm Disp
#*28 Syringe Refills:*0
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every 4 hours Disp #*84
Capsule Refills:*0
5. Aspirin 81 mg PO DAILY
6. Lumigan (bimatoprost) 0.01 % ophthalmic BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ledt intertrochanteric fracture
Discharge Condition:
AAOx3, mentating appropriately. NVI
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- WBAT LLE
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
WBAT LLE
Treatments Frequency:
change dressing if saturated or q3 days until follow up. ___
shower with tegaderm dressing in place
Followup Instructions:
___
|
10418336-DS-19 | 10,418,336 | 26,475,213 | DS | 19 | 2138-08-18 00:00:00 | 2138-08-29 11:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Dilaudid (PF)
Attending: ___
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
Upper GI endoscopy
History of Present Illness:
Mrs. ___ is a ___ year old female with history of Crohn's
presenting with intermittent epigastric abdominal pain since
___ that has worsened overnight. She has tried percocet,
which she usually takes for menstrual cramps, but was unable to
sleep from the abdominal pain. She reports not having a bowel
movement for the last two days and start miralax this morning
for constipation. She reports having flatus and nausea. She
denies fever, chills, vomiting, bloody stools. She does not
think this is a Crohn's flare. She states that she frequently
had sour taste in her mouth and heartburn for the last month.
Of note, she was treated with ibuprofen for retinitis before
started to have symptoms of reflux. Her last menstrual period
was ___ and denies vaginal discharge, pain, and possibility
of being pregnant.
.
Initial VS in the ED: 98.2 75 100/53 16 100%. Patient was given
1L of NS bolus, morphine, maalox, failed PO challenge. Inital
labs revealed normal BMP, CBC, LFT, and lipase. LDH was
elevated due to hemolyzed specimen. Patient also received GI
cocktail with lidocaine for pain, but vomited it up as it caused
abdominal pain and nausea. CT scan was obtained which showed
mild inflammation in the terminal ileum with associated
lymphadenopathy.
.
On the floor, patient continues to have persistent epigastric
pain that radiates to her right CVA. She also reports right
wrist pain that is worsened with flexion, mild headache. She
denies fever, chills, night sweats, weight loss or gain, cough,
rhinorrhea, shortness of breath, chest pain, palpitations,
change in bowel or bladder habits, or dysuria.
Past Medical History:
1. Crohn's disease - Used to get remicade infusion,stopped due
to recurrent infections. Treated in early/mid ___ for
retinitis with ibuprofen. Had perianal fistulas in ___ and
___ of this year.
2. Exercise induced asthma
3. C-section x2
Social History:
___
Family History:
No family members with IBD; younger sister with IBS.
Female members of the family have hypothyroid.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.2 BP: 102/60 P: 69 R: 18 O2: 99%RA
General: Alert, oriented, no acute distress, in mild discomfort.
Pear-shaped body habitus.
HEENT: Sclera anicteric, dry mucous membrane, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, distended, tender to palpation in epigastrium and
RUQ, bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Back: No tenderness to palp over spine, R CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 99.2 Tc 99.2 P 72(66-72) BP 98/54(94-102/54-60) RR 18
O2Sat99%RA
General: NAD
HEENT: PERRLA, EOMI, MMM
Lungs: Good air movement bilat, no wheezing/rhonchi/rales
CV: RRR, S1 S2, no m/r/g
Abdomen: soft, ND, NT, no appreciable organomegaly
Ext: WWP, no c/c/e
Other: CN II-XII intact, no gross motor/sensory deficit
Pertinent Results:
ADMISSION LABS:
___ 04:50AM BLOOD WBC-7.0 RBC-4.35 Hgb-12.2 Hct-38.0 MCV-87
MCH-28.1 MCHC-32.2 RDW-12.6 Plt ___
___ 04:50AM BLOOD Neuts-64.4 ___ Monos-4.4 Eos-2.4
Baso-0.8
___ 04:00PM BLOOD ESR-25*
___ 04:00PM BLOOD CRP-1.4
___ 04:50AM BLOOD ALT-15 AST-31 LD(LDH)-353* AlkPhos-42
TotBili-0.4
___ 04:50AM BLOOD Glucose-95 UreaN-11 Creat-0.8 Na-138
K-5.0 Cl-105 HCO3-22 AnGap-16
.
MICROBIOLOGY DATA:
___ 4:00 pm SEROLOGY/BLOOD OLD S# ___.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
.
RADIOGRAPHIC STUDIES:
KUB UPRIGHT AND SUPINE
UPRIGHT AND SUPINE VIEWS OF THE ABDOMEN: There is a
non-obstructive bowel gas pattern with a moderate amount of
stool seen extending to the cecum. No free air is seen. The
imaged portions of the heart and lung are grossly
unremarkable. Sacroiliac joints are unremarkable.
IMPRESSION: No obstruction
.
CT ABDOMEN
ABDOMEN: The visualized lung bases are normal, without pleural
effusion or
pneumothoraces. The imaged heart is unremarkable and there is
no pericardial effusion.
.
The liver is normal in contour. There are no focal liver
lesions identified. The gallbladder is unremarkable and there is
no intrahepatic biliary ductal dilatation. The spleen, pancreas
and adrenal glands are normal. The kidneys enhance symmetrically
and excrete contrast without hydronephrosis. There is no
retroperitoneal lymphadenopathy. No free air or free fluid is
seen. The stomach and small bowel are normal. The abdominal
aorta and its major branches are unremarkable. The portal vein,
splenic vein and superior mesenteric vein are patent.
.
PELVIS: At the terminal ileum there is a small segment of mural
hyperenhancement and mild fat stranding. Proximal to this there
is distention and fecalization of contents within the distal
ileum, with a short segment area (~1cm) of luminal narrowing, as
seen on prior studies. An adjacent prominent 8-mm lymph node is
noted. There is no free air or drainable fluid collection. No
fistula formation is present. The bladder, rectum and sigmoid
are normal. The uterus is unremarkable. Within the right
adnexa is a corpus luteal cyst with adjacent free fluid seen in
the pouch of ___.
.
BONES: There are no suspicious osseous lesions. The sacroiliac
joints are
unremarkable.
.
IMPRESSION:
1. Findings suggestive of active on chronic Crohn disease
involving the
terminal ileum. A short segment stricture at the terminal ileum
with mild small bowel dilatation proximal to this area is
similar compared to prior
studies. No abscess or fistula.
2. Right adnexal corpus luteum cyst with small amount of
adjacent free fluid.
.
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-6.5 RBC-4.07* Hgb-11.4* Hct-35.2*
MCV-87 MCH-28.0 MCHC-32.3 RDW-12.6 Plt ___
___ 05:30AM BLOOD ___ PTT-27.9 ___
___ 05:30AM BLOOD TSH-1.1
.
PENDING LABS:
1) Pathology report for GI tissue biopsy from EGD
Brief Hospital Course:
Mrs. ___ is a ___ year old female with history of Crohn's
presenting with epigastric abdominal pain and EGD findings
consistent with gastritis.
.
# Gastritis:
Patient described epigastric pain that intermittently radiated
to her back. Patient's history consistent with GERD and heavy
ibuprofen use prior to her GERD symptoms was highly suspicious
for peptic ulcer disease secondary to NSAID use. CT study showed
ruptured luteal cyst and inflammation of patient's terminal
ileum and associated lymphadenopathy. It did not show
perforation or free air in the abdomen that could potentially
explain her epigastric pain. Laboratory findings were not
consistent with Crohn's flare, pancreatitis, or cholecystitis.
Patient was started on PPI and opioids. Gastroenterology was
consulted and patient underwent an upper GI endoscopy, which
showed gastritis. H. pylori test was negative. Once patient
tolerated PO intake after the endoscopic procedure, she was
discharged on pain medications and omeprazole. Please follow up
as outpatient to assess her epigastric discomfort, diet and
sleep habit modifications. Also, patient has tissue biopsy from
her EGD pending.
.
# Crohn's:
Patient has an extensive history of Crohn's disease. She used
to receive remicade, but stopped receiving it due to frequent
perianal fistula/abscess formation and infection. She notes
that she had to be treated for retinitis a month ago. During
this hospitalization, patient did not have loose or bloody stool
and did not have her typical Crohn's flare associated pelvic
pain. Although CT findings were suspicious of a Crohn's flare,
her CRP and ESR were not consistent with a Crohn's flare.
Please follow up with patient regarding her Crohn's disease
management and consider restarting her on remicade.
.
# Headache:
Patient reported headaches that made her feel nauseous as well.
Zofran was given to control her nausea. Given her history of
drinking caffeinated beverages on a daily basis, this was
thought to be a caffeine withdrawal headache. Patient was given
fioricet and she responded well.
.
# TRANSITIONAL ISSUES:
1) Follow up patient's EGD biopsy results
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN
menstrual cramps
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO ONCE Duration: 1 Doses
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg DAILY Disp
#*10 Capsule Refills:*0
2. Docusate Sodium 100 mg PO BID
hold if having diarrhea
RX *docusate sodium 100 mg TWICE DAILY Disp #*28 Capsule
Refills:*0
3. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg TWICE DAILY Disp #*60 Capsule Refills:*2
4. Multivitamins 1 TAB PO DAILY
5. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN
menstrual cramps
RX *oxycodone-acetaminophen 5 mg-500 mg every six (6) hours Disp
#*15 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1) Gastritis secondary to NSAID use
.
SECONDARY DIAGNOSES:
1) h/o Crohn's disease
Discharge Condition:
Alert and oriented to time, place, and person.
Independently ambulatory.
Clinically stable and improved.
Discharge Instructions:
You were admitted to the medicine service for workup and
evaluation of your upper abdominal pain.
.
Your stomach pain is likely from gastritis. This was confirmed
on upper GI endoscopy study as well. Given the heavy ibuprofen
use last month, this is likely a consequence of excessive
ibuprofen use leading to irritation of the stomach lining.
Please do not take any ibuprofen unless you are told to
specifically by a physician. You may use Tylenol for pain or
fever instead of ibuprofen or motrin. Please avoid chocolate,
peppermint, alcohol, caffeine, onions, ibuprofen, motrin, and
aspirin. Elevate the head of the bed 3 inches or use two pillows
when you sleep and go to bed with an empty stomach. Please
continue to take pantoprazole as directed to suppress stomach
acid production.
.
Given your history of Crohn's disease, a CT scan was obtained.
It showed inflammation in the terminal ileum with associated
enlarged lymph nodes. However inflammatory markers in your blood
was not elevated and our suspicion of this being a Crohn's flare
is low. However, you should follow up with your
gastroenterologist and discuss restarting remicade.
.
You also had headaches that are thought to be caffeine
withdrawal headaches. The headache responded to fioricet. At
discharge you were given a prescription of fioricet to last a
few days so that you can taper off caffeine. Please take it
only when you have headaches and spread out the interval as much
as you can and when you run out, please only use Tylenol for
headaches.
.
You also reported having constipation. You were started on
senna, colace, and miralax to treat your constipation. Please
take these regularly until you start having normal bowel
movement. If you have diarrhea, please stop taking these
medications. Also, try not to use narcotic pain medications
(percocet, morphine, etc) if possible as they cause
constipation.
.
MEDICATION CHANGES:
1) START Pantoprazole 40 mg BY MOUTH TWICE DAILY
2) START Fioricet 1 tab AS NEEDED FOR HEADACHE
3) START Colace 100 mg TWICE DAILY AS NEEDED FOR CONSTIPATION
Followup Instructions:
___
|
10418457-DS-8 | 10,418,457 | 26,134,645 | DS | 8 | 2163-08-08 00:00:00 | 2163-08-08 16:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
jaw pain, bilateral
Major Surgical or Invasive Procedure:
___ ORIF of mandibular fracture
History of Present Illness:
Mr. ___ is a ___ presented to ___ after assault with
jaw pain and malocclusion. Patient reports he was intoxicated
and was punched in the face. Denies LOC. Complains of pain just
in jaw. Denies SOB, throat swelling. Patient was transferred
from ___ for further management. Imaging shows bilateral
mandible fractures. Has been evaluated by ___ who placed bridle
wire to approximate and reduce mobile parasymphysis segments.
Past Medical History:
Denies past medical or surgical history.
Social History:
___
Family History:
Noncontributory
Physical Exam:
Vitals: T97.8 HR 58 BP 140/90 RR 16 SAT 100%RA
General: Pt is awake alert and oriented.
HEENT: Mandible appears diffusely, symmetrically swollen, no
significant erythema. Mild ttp appropriate throughout. Mucosa
are pink and moist. Pupils are ERRLA with EMOI grossly.
CV: RRR, No MRG.
Lungs: good aeration, CLAB.
Abd: no masses or organomegaly, no guarding, benign.
Extremities: No deformity or edema
Pertinent Results:
___ 05:38AM BLOOD WBC-3.6* RBC-4.92 Hgb-13.4* Hct-42.0
MCV-85 MCH-27.2 MCHC-31.9* RDW-13.5 RDWSD-42.4 Plt ___
___ 05:55PM BLOOD WBC-5.9 RBC-4.79 Hgb-13.2* Hct-41.1
MCV-86 MCH-27.6 MCHC-32.1 RDW-13.8 RDWSD-43.1 Plt ___
___ 05:38AM BLOOD Glucose-92 UreaN-6 Creat-0.9 Na-138 K-4.1
Cl-102 HCO3-26 AnGap-14
___ 05:55PM BLOOD Glucose-76 UreaN-10 Creat-1.0 Na-138
K-4.0 Cl-102 HCO3-26 AnGap-14
MANDIBLE PANOREX ___
Right parasymphyseal fracture of the mandible involving the
alveolar process
and extending between the central incisors ___ teeth #24 and
#25) is re-
demonstrated. There has been interval placement of a cerclage
wire about the lower central incisors. Fracture of the left
mandibular ramus is nondisplaced and demonstrates extension to
the coronoid process and mandibular notch.
IMPRESSION:
Right parasymphyseal and left mandibular ramus fractures.
Brief Hospital Course:
Mr. ___ is a ___ who presented to ___ ___ after
assault to face with jaw pain and malocclusion. Patient reports
he was intoxicated and was punched in the face. Denies LOC.
Complains of pain just in jaw. Denies SOB, throat swelling.
Patient was transferred from ___ for further management. CT
mandible (panorex) done at admission showed right parasymphysis
fracture, left mandibular ramus fracture for which ___ placed
bridle wire to approximate and reduce mobile parasymphysis
segments. On ___, after informed consent was obtained, Mr.
___ was taken to the OR with ___ for: Open Reduction
Internal Fixation of parasymphysis fracture and Closed reduction
maxillo-mandibular fixation. He was given antibiotics
perioperatively and instructed to continue these for 6 days
following discharge. He was also instructed to use a
clorhexadine mouthwash to rinse with twice daily for a minimum
of two weeks. He was advanced to a full liquid diet with
supplementation shakes and tolerated this well. Once he met the
appropriate criteria he was dischaged home and instructed to
follow up in the ___ clinic as scheduled.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg/5 mL ___ mL by mouth every 6 hours
Refills:*0
2. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium [Diocto] 50 mg/5 mL ___ mL by mouth twice
daily Refills:*0
3. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 5 mL by mouth every 4 hours Refills:*0
4. cephALEXin 250 mg/5 mL oral TID
last dose on ___
RX *cephalexin 250 mg/5 mL 10 mL by mouth three times per day
Refills:*0
5. Peridex (chlorhexidine gluconate) 0.12 % mucous membrane BID
Duration: 14 Days
RX *chlorhexidine gluconate [Paroex Oral Rinse] 0.12 % Rinse
with 15mL twice a day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
bilateral mandible fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
You were admitted to the hospital after an assault in which
sustained a fracture to your jaw. You were taken to the
operating room to have your jaw repaired. You are slowly
recovering from your surgery. You are preparing for discharge
home with the following instructions:
Followup Instructions:
___
|
10418457-DS-9 | 10,418,457 | 24,985,646 | DS | 9 | 2164-05-21 00:00:00 | 2164-05-22 17:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Jaw pain
Major Surgical or Invasive Procedure:
___:
1. Placement of Six IMF screws.
2. Open reduction internal fixation of the left angle fracture
via transcervical approach.
3. Simple extraction of tooth #17
History of Present Illness:
Mr. ___ is a ___ year old male, with h/o previous b/l
mandibular fx s/p right mandibular repair, who is now
transferred
from ___ with a new left mandibular fracture after
being assaulted ___ days ago. He was punched multiple times in
the left side of face and the left chest. He also reports
chronic
pain of the right ankle and foot. He has no chest pressure,
shortness of breath, abdominal pain, nausea, vomiting, fever, or
chills. He initially presented to ___ but had an altercation in
the ED and was reportedly dismissed from the ED. Over past few
days, the pain had worsened so he presented to ___
where he had a negative CT head for intracranial bleed and left
shoulder and chest x-rays were largely unremarkable. There was a
new left mandibular fracture for which, per his preference, he
was transferred to ___ for ___ evaluation. He is being
admitted to the Trauma/Acute Care Surgery service for OR with
___.
Past Medical History:
Past Medical History:
None
Past Surgical History:
___ - Open reduction internal fixation of the mandible at
right parasymphysis by intraoral approach
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: T 97.7, HR 63, BP 136/89, RR 16, SaO2 100% RA
GEN: Alert and oriented, no acute distress, conversant and
interactive. Unable to move mouth and lips well
HEENT: Sclerae anicteric, mucous membranes moist, oropharynx is
clear. Clearing secretions
NECK: Trachea is midline, thyroid unremarkable, no palpable
cervical lymphadenopathy,
CV: Regular rate and rhythm, no audible murmurs.
PULM/CHEST: Clear to auscultation bilaterally, respirations are
unlabored on room air.
ABD: Soft, nontender, nondistended, no guarding or rebound
tenderness
Ext: No lower extremity edema, distal extremities feel warm and
appear well-perfused. Right ankle with tenderness, but able to
move
Pertinent Results:
Imaging:
___ Right ankle:
1. No evidence of an acute fracture or dislocation.
2. Healing medial malleolus fracture.
3. Prior syndesmotic injury.
___ Mandible:
Mildly distracted oblique fracture through the left mandibular
body extending to the root of a left lower molar tooth ___
tooth 17). Prior fractures of the left mandibular ramus and
right parasymphyseal mandible are less evident on the current
exam.
___ Rib:
No acute cardiopulmonary abnormality. No definite rib fracture
seen.
Brief Hospital Course:
Mr. ___ is a ___ yo M admitted to the Acute Care Trauma
Service after sustaining multiple punches to the face and chest.
Past med/surg history significant for an ORIF of aright
parasymphysis and CRMMF of the left ramus mandibular fracture 8
months ago. He had a CT scan of the face that showed a displaced
and open left mandibular angle fracture extending mesial to
tooth #17.
He was seen and evaluated by the ___ team who recommended
surgical repair. On HD3 he was taken to the operating room for
an ORIF of the left mandible. The patient tolerated the
procedure well. Please see operative report for details. After a
brief, uneventful stay in the PACU, the patient arrived on the
floor tolerating sips, on IV fluids, and liquid oxycodone for
pain control. The patient was hemodynamically stable. The
surgical drain was removed on POD1.
Social work was consulted for history of multiple assaults. The
recommended psychiatric evaluation for thought of harming
others. Psychiatry cleared the patient for discharge.
Pain was well controlled. Diet was progressively advanced as
tolerated to a full liquid diet with good tolerability. The
patient voided without problem. During this hospitalization, the
patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a full
liquid diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was homeless and given a list
of shelters and resources at the time of discharge. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
He had follow-up scheduled with the ___ clinic.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
RX *acetaminophen [Children's Acetaminophen] 325 mg/10.15 mL 650
mg by mouth every six (6) hours Disp #*1000 Milliliter
Refills:*0
2. Cephalexin 500 mg PO Q8H Duration: 5 Days
RX *cephalexin 250 mg/5 mL 10 mL by mouth every eight (8) hours
Disp ___ Milliliter Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % swish and spit twice a day
Disp #*420 Milliliter Refills:*0
4. Docusate Sodium (Liquid) 100 mg PO BID
please hold for loose stool
RX *docusate sodium 50 mg/5 mL 10 mL by mouth twice a day Disp
___ Milliliter Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left Mandiubular body to root of left molar fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care Trauma surgery service after
an assault. You were found to have a fracture of your left jaw.
You were taken to the operating room with the ___ (oral
maxillofacial-surgery) team and had your jaw repaired with one
tooth extracted. You are now doing better, tolerating a full
liquid diet, and ready to be discharged home to continue your
recovery. You will be sent home with a prescription for
antibiotics, please complete the full course.
You were also seen by Orthopedics for right ankle pain due to an
old medial malleolus facture. An xray was taken which was
negative, and the Orthopedic team recommended continuing the air
boot and weight bearing as tolerated.
Please note the following discharge instructions:
Regarding your Oral Surgery:
-Please remain on a full liquid diet for the next ___ weeks
until your follow-up appointment with ___
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery
Followup Instructions:
___
|
10418685-DS-7 | 10,418,685 | 21,114,401 | DS | 7 | 2158-03-13 00:00:00 | 2158-03-13 18:04:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
peanut
Attending: ___.
Chief Complaint:
Anaphylactic Shock
Major Surgical or Invasive Procedure:
Intubated by EMS PTA ___
History of Present Illness:
___ is an ___ female with no known PMHx except for a
peanut allergy presented in anaphylactic shock. Reportedly
accidentally ate a cookie that contained peanut butter. She
walked to ___ to get Benadryl, but collapsed. Upon EMS arrival
the patient was cyanotic with agonal breathing and was intubated
in the field. She received Epi 2.3mg x2, Solumedrol 125mg,
Versed 10mg, Fentanyl 50mg, Succinylcholine 120mg.
Past Medical History:
None
Social History:
___
Family History:
unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.2F, HR 109, BP 126/102, RR 13, SpO2 100% Intubated
GENERAL: Intubated, sedated, following commands
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
NECK: Supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Soft, ___, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rashes or lesions
NEURO: Moving all extremities on command
DISCHARGE PHYSICAL EXAM:
========================VS: 98.8 PO 109 / 69 R Lying ___
Ra
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
good
dentition, No tongue swelling, no oropharyngeal erythema
NECK: nontender supple neck, no LAD, no JVD, no stridor
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: diffuse exp wheezes, moving air well in all lung fields,
breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CNsgrossly intact, moving all four extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LAB RESULTS:
======================
___ 03:45AM BLOOD ___
___ Plt ___
___ 03:45AM BLOOD ___
___ Im ___
___
___ 05:24AM BLOOD ___ ___
___ 02:30AM BLOOD ___
___
___ 05:24AM BLOOD ___
___ 05:59AM BLOOD ___
___ Base XS--4
___ 05:59AM BLOOD ___
MICROBIOLOGY:
=============
1. Blood culture ___: Pending
2. Urine culture ___: Pending
3. Urine culture ___: Negative for Legionella
IMAGING:
========
1. CXR ___: The endotracheal tube projects over the distal
thoracic trachea. Enteric tube is seen below the diaphragm and
with tip projecting over the right upper abdomen. There is mild
pulmonary vascular congestion without overt pulmonary edema.
The lungs are clear. The heart size is within normal limits.
There is no pleural effusion or pneumothorax.
2. CXR ___: Patient has been extubated in the NG tube has
been removed. Lungs are low volume with minimal bibasilar
atelectasis. Patchy opacity in the left lower lobe could
represent atelectasis however aspiration pneumonia cannot be
excluded. No pneumothorax is seen
Brief Hospital Course:
BRIEF SUMMARY:
___ w/ no known PMHx besides a peanut allergy who presents in
anaphylactic shock after an accidental peanut butter ingestion
and required epinephrine drip, intubation, and was successfully
extubated and monitored on the floor prior to discharge.
# Anaphylactic Shock
# Hypoxemic respiratory failure
# Suspected resolving URI
___ is an ___ female with no known PMHx except for a
peanut allergy presented in anaphylactic shock. Reportedly
accidentally ate a cookie that contained peanut butter. She
walked to ___ to get Benadryl, but collapsed. Upon EMS arrival
the patient was cyanotic with agonal breathing and was intubated
and sedated in the field. Initially admitted to the ICU and
required epinephrine gtt, which was weaned off. Also given
famotidine and solumedrol. Patient successfully extubated and
monitored on the floor with improved symptoms prior to
discharge. She was febrile while in the ICU and was initially
started on antibiotics due to concern for pneumonia. However
upon further review of her CXR and her recent symptoms, this
seemed much more likely a resolving aspiration pneumonitis,
manifestation of her anaphylaxis, and/or ___ viral
illness, and less likely a bacterial pneumonia, so these
antibiotics were discontinued prior to discharge. The patient
had some mild wheezing prior to discharge but reported that she
had this had been present prior to her anaphylaxis, likely due
to her respiratory viral illness. She denied dyspnea, cough, and
was not hypoxic. She also denied any pruritis or rashes.
Therefore she was prescribed one additional day of
corticosteroid treatment but not continued on antihistamines or
antibiotics.
TRANSITIONAL ISSUES
- Prescribed prednisone 40mg once to take on ___, then
discontinue
- ___ to establish care with a PCP
- ___ to see an Allergist
- ___ to carry an Epipen with her at all times
# Communication: mom ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection ONCE
RX *epinephrine 0.3 mg/0.3 mL 0.3 ml IM Once Disp #*2 Package
Refills:*0
2. PredniSONE 40 mg PO DAILY Duration: 2 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Anaphylactic Shock
# Hypoxic Respiratory Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were recently seen at ___.
WHY YOU WERE HERE:
You were here for a severe allergic reaction called anaphylaxis.
WHAT HAPPENED WHILE YOU WERE HERE:
Before you got to the hospital, you were intubated to help you
breathe and protect your airway. You received rescue medications
including an ___ and steroids. You were admitted to the ICU
where we continued those medications to help control your blood
pressure.
We now feel it is safe to send you home. It is very important
that you try and avoid peanuts or products that contain peanuts.
Because accidents can happen, it is very important that you
carry an ___ on you at all times.
Please follow up with your primary care provider.
Please schedule an appointment with an allergist for further
evaluation.
Please take prednisone 40mg on ___.
If you develop fevers, cough or purulent sputum, please see your
doctor given concern for possible pneumonia.
You should call your doctor or return to the ER:
* if you have any new rash or itchiness
* if you notice any swelling of your face or neck
* if you are having trouble breathing
* if you have any questions or concerns
Thank you for choosing ___ ___ ___ for
your health care ___.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10418790-DS-3 | 10,418,790 | 22,227,807 | DS | 3 | 2129-09-09 00:00:00 | 2129-09-09 10:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
Right tibial plateau ORIF
History of Present Illness:
Mrs. ___ is a ___ who sustained a fall 2 days ago and
injured
her right knee. She was walking with a cane outside and fell.
She
hit had positive head strike but did not lose consciousness. She
was with her friends, who took her home. Today, she was found by
neighbor on the floor and does not remember falling, nor does
she
remember how long she was down for. She was taken to ___, where a CT was performed, which demonstrated a R
tibial
plateau fracture.
She has PMH of NPH s/p VP shunting with history of multiple
falls, CAD s/p MI, MVR w/ bioprosthetic valve, AFib on
dabigatran, HTN, and CHF
She has history of falls in the past when NPH was uncontrolled.
She denies any distal paresthesias. She does have back pain.
Past Medical History:
- CAD s/p MI
- CHF (unknown EF)
- atrial fibrillation (CHA2DS2-Vasc=6, on dabigatran)
- s/p MVR w/ bioprosthetic valve
- HLD
- HTN
- s/p AICD placement
Social History:
___
Family History:
noncontributory
Physical Exam:
AVSS
NAD, A&Ox3
RLE: dressing CDI. Fires FHL, ___, TA, GCS. SILT ___ n
distributions. wwp distally.
Pertinent Results:
___ 07:20AM BLOOD WBC-9.9 RBC-4.45 Hgb-13.1 Hct-38.9 MCV-87
MCH-29.4 MCHC-33.7 RDW-15.5 RDWSD-49.2* Plt ___
___ 07:20AM BLOOD WBC-10.6* RBC-3.67* Hgb-10.6* Hct-32.8*
MCV-89 MCH-28.9 MCHC-32.3 RDW-15.6* RDWSD-51.6* Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right tibial plateau ORIF, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweight bearing in the right lower extremity, and will be
discharged on home dabiatran for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*120 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*35 Tablet Refills:*0
4. Dabigatran Etexilate 150 mg PO BID
5. Digoxin 0.125 mg PO DAILY
6. Enalapril Maleate 20 mg PO DAILY
7. Enalapril Maleate 10 mg PO QPM
8. Enalapril Maleate 10 mg PO QPM
9. Metoprolol Succinate XL 50 mg PO TID
10. Simvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right tibial plateau fracture
Discharge Condition:
AVSS
NAD, A&Ox3
RLE: Dressing CDI. Fires FHL, ___, TA, GCS. SILT ___ n
distributions. wwp distally.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Nonweight bearing right lower extremity, range of motion as
tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please resume your home dabigatran.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Nonweight bearing right lower extremity, range of motion as
tolerated
Treatments Frequency:
Dry sterile dressing changes as needed
Followup Instructions:
___
|
10419066-DS-4 | 10,419,066 | 23,312,315 | DS | 4 | 2152-01-02 00:00:00 | 2152-01-02 22:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
abd pain, N/V
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with a PMH of chronic Hep B,
H/ pylori s/p treatment with Prevpac, laparoscopic
cholecystectomy for biliary colic in ___, who presents
with abdominal pain.
Patient reports that two days ago she was in her usual state of
health until two days ago. She ate lunch and went to her
appointment in ___ clinic. She reports that while there
she suddenly felt sweaty, followed by sudden onset of sharp,
severe abdominal pain in the epigastric area, associated with
nausea. She went to the ED, where she reports she had an
ultrasound and labs. Her symptoms resolved, and she was
discharged home. However, the following day she ate oatmeal, and
around 30 minutes later again suddenly became diaphoretic with
epigastric pain and nausea. She again presented to the ED. She
reports no fevers or chills, no rashes, no change in bowel
movements.
In the ED:
Initial vital signs were notable for: T 97.9, HR 65, BP 123/81,
RR 16, 100% RA Exam notable for: Tenderness to palpation to the
epigastric region.
Labs were notable for:
- CBC: WBC 6.6 (52%n), hgb 13.8, plt 201
- Lytes:
143 / 107 / 13 AGap=17
------------- 80
4.2 \ 19 \ 0.7
- LFTs: AST: 405 ALT: 393 AP: 176 Tbili: 1.3 Alb: 4.2
- lipase 22
- lactate 1.4
- u/a with lg leuks, trace blood, trace protein, 40 ketones,
>182
WBCs, negative nitrites, no bacteria
Upon arrival to the floor, patient reports continued abdominal
pain and nausea which comes and goes. She feels that the nausea
may have been from her morphine. Otherwise she recounts the
history as above.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- chronic hep B infection
- biliary colic s/p laparoscopyic cholecystectomy
- hypertension
- peptic ulcer disease
- liver hemangiomas
- renal cyst
- plantar fasciitis
- Alopecia areata
Social History:
___
Family History:
- Mother Living ___ BREAST CANCER
- Father ___ ___ HYPERTENSION, DIABETES TYPE II, STROKE
- Brother Living ___ HYPERTENSION
- Aunt Deceased ___ PANCREATIC CANCER
Physical Exam:
VITALS: T 97.9, HR 68, BP 109/73, RR 18, 98% RA
GENERAL: Alert and in no apparent distress, appearing in pain
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Hypoactive bowel sounds. Abdomen soft, non-distended,
moderately tender to palpation in epigastric area. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
98.2 127/___
GEN: female in NAD
HEENT: MMM, no scleral icterus
CV: RRR no m/r/g
RESP: CTAB no w.r
ABD: soft, NT, ND, NABS
GU: no foley
EXTR: warm, no edema
NEURO: alert, appropriately, moving all extremities
PSYCH: calm, pleasant affect
Pertinent Results:
___ 07:25PM BLOOD WBC-6.6 RBC-4.53 Hgb-13.8 Hct-42.6 MCV-94
MCH-30.5 MCHC-32.4 RDW-12.8 RDWSD-44.4 Plt ___
___ 07:30AM BLOOD WBC-5.4 RBC-4.48 Hgb-13.7 Hct-42.3 MCV-94
MCH-30.6 MCHC-32.4 RDW-12.6 RDWSD-43.8 Plt ___
___ 07:25PM BLOOD Glucose-80 UreaN-13 Creat-0.7 Na-143
K-4.2 Cl-107 HCO3-19* AnGap-17
___ 07:30AM BLOOD Glucose-83 UreaN-6 Creat-0.7 Na-146 K-3.8
Cl-107 HCO3-27 AnGap-12
___ 07:25PM BLOOD ALT-393* AST-405* AlkPhos-176*
TotBili-1.3
___ 12:53PM BLOOD ALT-574* AST-425* AlkPhos-207*
TotBili-2.5*
___ 06:32AM BLOOD ALT-408* AST-174* AlkPhos-191*
TotBili-0.9
___ 07:30AM BLOOD ALT-283* AST-69* AlkPhos-174* TotBili-0.5
RUQ US ___:
1. Mild intrahepatic biliary ductal dilation in this patient
post
cholecystectomy. No definite evidence for a retained
obstructing duct stone.
2. Echogenic foci within the right kidney, similar to prior
likely
representing angiomyolipomas.
3. Hepatic hemangioma again noted.
RUQ U/s ___ile duct is seen to measure up to 10 mm, likely
slightly increased
as it was previously seen to measure up to 7 mm. No retained
stone is seen in
the visualized portion of the duct.
MRCP:
Mild dilation of the extrahepatic bile duct with focal caliber
change in the
distal CBD near the ampulla, without definite evidence of an
obstructing stone
or lesion. Further evaluation with EUS/ERCP is recommended.
Urine Cx negative for growth
Cdiff PCR negative
Stool Culture pending at the time of discharge
Brief Hospital Course:
___ y/o F with PMHx of chronic Hep B, H pylori s/p treatment and
s/p laparoscopic CCY in ___ who presents with abdominal pain
with N/V, dilated biliary tree on imaging and
elevated/obstructive LFTs. MRCP shows change in caliber of
distal CBD though no obvious stones. Symptoms and lab
abnormalities resolved without intervention and pt has close
follow up planned with ERCP team for procedure.
ACUTE/ACTIVE PROBLEMS:
# Abdominal pain/Biliary obstruction at CBD: Pt presented with
___ days of epigastric pain, N/V and diarrhea. Evaluation
revealed abnormal LFTs with Tbili of 2.5 and dilated biliary
tree with concern for atypical findings at distal CBD. ERCP
team was consulted and followed through admission. Pt was
managed conservatively with bowel rest and IVF with resolution
of symptoms. Pt was advanced a diet without any difficulty,
symptoms resolved without intervention. Tbili and Alk phos
normalized, transaminitis rapidly downtrending. ERCP team will
review her imaging/course at multidisciplinary pancreas
conference on ___ and will contact the patient next week to
schedule a follow up ERCP (likely with EUS). Given that
symptoms resolved without intervention and pt was doing well
with a regular diet, it was felt reasonable to discharge home
with clear instructions about indications to return for urgent
evaluation. Pt and husband expressed understanding about the
need for procedure in the next ___ weeks to further evaluate
this finding.
# Pyuria: Pt denied any lower abdominal symptoms or symptoms of
UTI despite many WBCs in urine. Two urine cultures were negative
for growth. Pt was aggressively hydrated during admission.
# Hypertension - Lisinopril was held in setting of poor oral
intake. BP remained normal and lisinopril was held on discharge
with plan to re-assess BP when pt is seen by PCP.
# Chronic hep B
# Hepatic hemangiomas: followed by hepatology as outpatient
Transitional issues:
1) Abnormal finding at CBD, awaiting procedure plan with ERCP
team
2) Holding Lisinopril until seen by PCP ___ 2 weeks, can likely
be restarted at this appointment
3) Recommend follow up LFTs in ___ weeks
> 30min spent on clinical care on the day of discharge including
time coordinating transition and providing bedside education to
patient/family regarding follow up and next steps.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Mirena (levonorgestrel) 20 mcg/24 hours ___ yrs) 52 mg
intrauterine continuous
Discharge Medications:
1. Mirena (levonorgestrel) 20 mcg/24 hours ___ yrs) 52 mg
intrauterine continuous
2. Vitamin D ___ UNIT PO DAILY
3. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you are seen by your primary care
physician
___:
Home
Discharge Diagnosis:
Biliary obstruction
Possible Common bile duct abnormality
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain, nausea, vomiting and
abnormal liver function tests. You underwent imaging of the
biliary tree with MRCP that shows possible blockage at the
distal common bile duct. You have been evaluated by the ERCP
and have been advanced a diet without any recurrent symptoms.
The liver function tests are rapidly improving and the ERCP/GI
team will be reviewing all your information at the
multidisciplinary conference tomorrow evening. They will be
contacting you in the following days to help coordinate a follow
up procedure to further evaluate this finding.
You should continue on a low fat diet and monitor for any
recurrent symptoms of abdominal pain, nausea, vomiting or
fevers. Please returns for urgent evaluation if these occur.
We have been holding your Lisinopril due to mild dehydration on
admission. Please do not restart it until you are seen by your
primary care physician.
Best wishes from your team at ___
Followup Instructions:
___
|
10419282-DS-3 | 10,419,282 | 29,831,299 | DS | 3 | 2160-10-31 00:00:00 | 2160-10-31 11:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
mushrooms
Attending: ___.
Chief Complaint:
right upper extremity pain
Major Surgical or Invasive Procedure:
right elbow irrigation and debridement
History of Present Illness:
___ year old right-handed man has experienced approximately 24
hours of atraumatic right elbow pain and swelling. It has been
progressively worsening, resulting in now severe, dull pain that
is worse with even slight movements at the elbow. He has also
had atraumatic right wrist pain for many months, attributed to a
ganglionic cyst. He has not noted any skin injuries, insect
bites, denies fever and chills, denies any other arthralgias or
joint swelling. He denies any numbness, paresthesias, or
weakness.
At ___, arthrocentesis with >80k WBCs 88% neutrophils.
Received 1x dose of empiric vancomycin.
Past Medical History:
Hypercholesterolemia
PE on coumadin
Physical Exam:
RUE:
incision c/d/I
SILT A/M/U/R
Firing EPL/FPL, DIO
+2 pulses distally
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right upper extremity pseudogout and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for irrigation and debridement, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with outpatient ___ was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the right upper extremity
extremity, and will be discharged on his home coumadin for DVT
prophylaxis. The patient will follow up with Dr. ___
(___) per routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
Warfarin
Simvastatin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp
#*56 Capsule Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours Disp
#*42 Tablet Refills:*0
5. Linezolid ___ mg PO Q12H
RX *linezolid ___ mg 1 tablet(s) by mouth every 12 hours Disp
#*24 Tablet Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth ___ tablets every 4
hours for pain as needed Disp #*42 Capsule Refills:*0
7. Simvastatin 40 mg PO QPM
8. Warfarin 5 mg PO DAILY16
9.Outpatient Physical Therapy
weight bearing as tolerated right upper extremity
range of motion as tolerated right upper extremity
2-3/week
Discharge Disposition:
Home
Discharge Diagnosis:
right elbow pseudogout with probable superimposed infection
Discharge Condition:
NVI, AAOx3, mentating appropriately
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight bearing as tolerated
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please continue to take your coumadin
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Physical Therapy:
weight bearing and range of motion as tolerated, right lower
extremity
Treatments Frequency:
do not scrub your incision
Followup Instructions:
___
|
10419466-DS-11 | 10,419,466 | 21,024,440 | DS | 11 | 2183-02-27 00:00:00 | 2183-02-27 17:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metformin / gabapentin
Attending: ___.
Chief Complaint:
Abdominal pain, swelling, back pain
Major Surgical or Invasive Procedure:
- ___ biopsy of peritoneal masses, ___
- Therapeutic paracenteses, ___
- EGD, EUS, ___
- Colonoscopy, ___
History of Present Illness:
2 days PTA pt presented to his PCP endorsing back pain,
abdominal pain and bloating that began three weeks ago. His back
pain is in his lower back and worse on the left side
(paraspinal). His abdominal pain is strongest in the RLQ. The
back and abdominal pain are made worse by lying on his side.
They are not affected by eating. He also endorses two weeks of
periodic fits of dry cough that makes him feel nauseous
afterward. He has also noticed fatigue when climbing stairs, but
denies SOB. Additionally, he feels that his stools have been
thinner in caliber. Interestingly, he developed gout two months
prior to presentation. His last colonoscopy was in ___ and
showed benign sessile and hyperplastic polyps. He denies fevers,
chills, night sweats, weight loss, nausea, vomiting, black or
bloody stools, dysphagia, chest pain, dysuria, hematuria, fecal
or urinary incontinence. The pain is not affected by eating.
His PCP ordered an abdominal CT which showed ascites and omental
caking concerning for malignancy. He presented to the ED for
admission and further work up.
Past Medical History:
-DM2 w/ neuropathy
-HTN
-HLD
-CKD
-Gout in big toe on R foot(began two months ago)
Social History:
___
Family History:
Mother: ___ CA at ___
-No other family hx of CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vitals: Tc 98.3, BP 131/74, HR 95, RR 22, O2 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, PERRLA
Neck: Supple, no cervical, supraclavicular or axillary
lymphadenopathy
Lungs: CTAB no wheezes, rales, rhonchi, unlabored breathing
CV: RRR, Nl S1, S2, No MRG
Abdomen: soft, nontender, distended, +fluid wave, bowel sounds
present, no rebound tenderness or guarding
Back: No CVA tenderness, no tenderness over spinous processes
GU: Normal Rectal tone, and perianal sensation
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: AOx3, 3+ L patellar reflex, 2+ R patellar reflex, moving
all extremities spontaneously normal ___ strength
DISCHARGE PHYSICAL EXAM:
============================
Vitals: 99.9 | 98.8 | ___ | 96-102 | 18 | 93-98%RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - Soft, nontender, abdomen is less distended than
yesterday, no rebound or guarding
EXTREMITIES - WWP, no edema, 2+ peripheral pulses
NEURO - awake, A&Ox3, moving all extremities appropriately
Pertinent Results:
ADMISSIONS LABS:
================
___ 11:03AM BLOOD WBC-7.2 RBC-4.60 Hgb-11.3* Hct-37.1*
MCV-81* MCH-24.6* MCHC-30.5* RDW-13.6 RDWSD-39.7 Plt ___
___ 11:03AM BLOOD ___ PTT-28.3 ___
___ 11:03AM BLOOD Glucose-128* UreaN-16 Creat-1.1 Na-136
K-5.1 Cl-99 HCO3-26 AnGap-16
___ 11:03AM BLOOD ALT-10 AST-16 LD(LDH)-120 AlkPhos-85
TotBili-0.3
___ 11:03AM BLOOD Albumin-2.9* UricAcd-6.4
___ 06:23AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.8 UricAcd-6.3
___ 06:10AM BLOOD CEA-0.8
___ 06:20AM BLOOD CA12___*
___ 06:36AM BLOOD PSA-3.4
___ 06:20am BLOOD ___
IMAGING:
=======
___ CT ABDOMEN/PELVIS
1. Extensive omental caking and moderate to large ascites, with
no lesion
suspicious for primary neoplasm visualized. Omental biopsy is
recommended.
2. 6 mm ground-glass nodule at the right lung base, for which
follow-up CT is recommended in no more than ___ months.
RECOMMENDATION(S):
1. Recommend omental biopsy.
2. Recommend follow-up CT chest in no more than ___ months.
___ CT CHEST +CONTRAST
Pulmonary nodules as described, nonspecific but metastatic
disease cannot be excluded. Does short followup in 3 months is
recommended. Patulous esophagus. Ascites and peritoneal
carcinomatosis, partially imaged.
___ TOUCH PREP OF CORE BIOPSY, OMENTUM
Hypercellular atypical epitheliod cell proliferation, highly
suspicious for malignancy.
___ ULTRASOUND-GUIDED PARACENTESIS
Technically successful diagnostic and therapeutic ultrasound
guided
paracentesis. 4.2L straw colored clear fluid drained.
___ MRI L-SPINE
1. No evidence of metastatic disease.
2. Multilevel degenerate changes of the lumbar spine, progressed
and most
advanced at L4-5, where there is mild left neural foraminal
stenosis and
stable in the remainder of the lumbar spine. No spinal canal
stenosis.
___ ULTRASOUND-GUIDED PARACENTESIS
Technically successful ultrasound-guided therapeutic and
diagnostic
paracentesis, with removal of 0.5 L of straw-colored ascitic
fluid.
___ CT ABDOMEN/PELVIS +CONTRAST
1. No CT evidence of viscus perforation.
2. Unchanged extensive omental caking in comparison to the ___ CT.
3. Unchanged amount ascites.
4. No focal source of intraabdominal infection.
5. Mild prostatomegaly.
___ ULTRASOUND-GUIDED PARACENTESIS
Ultrasound-guided paracentesis from the right lower quadrant
with removal of 3.3 L turbid cream each fluid.
PATHOLOGY:
==========
___ STOMACH BIOPSY: chronic active gastritis with organisms
consistent with Helicobacter
___ DUODENAL POLYP BIOPSY: fragments of adenomatous mucosa;
no carcinoma seen in the fragments
___ PERITONEAL FLUID CYTOLOGY: negative for malignant fluids
___ COLONIC POLYP: adenoma
ENDOSCOPIC REPORTS:
===================
___ EGD: erythema & nodularity in the stomach body & antrum;
polyp in D2, 5 cm distal to the ampulla on the opposite wall;
otherwise normal EGD to D3
___ EUS: ascites & omental caking noted in the perigastric
area; otherwise normal upper EUS to D3; no source of primary
cancer identified
___ COLONSCOPY: polyp in ascending colon; grade 1 internal
hemorrhoids; otherwise normal colonscopy to cecum
MICROBIOLOGY:
=============
___ BLOOD CX: negative
___ PERITONEAL FLUID: Gram-stain with 2+ PMNs, no
microorganisms; culture negative.
___ 08:38AM ASCITES WBC-1105* RBC-68* Polys-18*
Lymphs-16* ___ Mesothe-1* Macroph-65*
___ 08:38AM ASCITES TotPro-4.0 Glucose-105 LD(LDH)-135
Albumin-2.0
___ PERITONEAL FLUID: Gram-stain with 4+ PMNs, no
microorganisms; culture negative
___ 03:36PM ASCITES WBC-2900* RBC-350* Polys-18*
Lymphs-22* Monos-58* Other-2*
___ PERITOINEAL FLUID: Gram-stain with 3+ PMNs, no
microorganisms; culture ___________
___ 08:40AM ASCITES WBC-1430* RBC-131* Polys-21*
Lymphs-5* Monos-0 Plasma-2* Mesothe-4* Macroph-67* Other-1*
___ 08:40AM ASCITES TotPro-3.7 LD(LDH)-124 Albumin-2.0
DISCHARGE LABS:
================
___ 06:10AM BLOOD WBC-8.2 RBC-4.08* Hgb-9.8* Hct-32.1*
MCV-79* MCH-24.0* MCHC-30.5* RDW-14.4 RDWSD-40.7 Plt ___
___ 04:45AM BLOOD ___ PTT-25.9 ___
___ 06:10AM BLOOD Glucose-140* UreaN-16 Creat-1.1 Na-140
K-5.3* Cl-104 HCO3-29 AnGap-12
___ 06:10AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
Brief Hospital Course:
This is ___ M w/ a PMH of HTN, DM, gout presenting w/ 3 weeks
of abdominal pain/distention, back pain and abdominal CT showing
peritoneal carcinomatosis and omental caking.
ACTIVE ISSUES:
# Omental caking: identified on imaging, without prior history
of malignancy. Evaluation for primary malignancy included serum
biomarkers (positive CA-125, negative CEA, ___, imaging
(nothing identified on thoracic imaging), EGD, EUS and
colonscopy - all of which failed to demonstrate primary source
of malignancy. Pulmonary nodules identified on CT chest, which
could represent metastatic disease.
- Touch prep biopsy concerning for mesothelioma, though repeat
biopsy done; pathology pending at discharge.
- If inconclusive, would consider bronchoscopic lung biopsy
- Patient will follow up with ___ Oncology for pending reports
# Ascites: patient without evidence or history of heart disease
or liver disease. Imaging demonstrated normal liver, without
abnormalities of LFTs. Omental caking likely the source for
ascites production.
# Bacterial peritonitis: initial paracentesis without evidence
of infection (cell counts, culture negative). Repeat
paracentesis with elevated PMNs (500), straw-colored, clear
fluid and peripheral leukocytosis. Treated with ceftriaxone for
7 days. Repeat paracentesis showed persistence of PMNs (280),
with turbid fluid, but no peripheral leukocytosis. Abdominal
exam remained benign. Culture of third tap pending at discharge.
CT abdomen/pelvis with oral contrast showed no evidence of
microperforation. **************** Discussion with ID ________.
Cellularity of ascites felt to be secondary to malignancy, and
not true infection, given clinical appearance. ************
#Back Pain: Pt endorsed 2 weeks of lower back pain made worse by
lying on side, without vertebral tenderness, incontinence,
decreased rectal tone, depressed perianal sensation or lower
extremity symptoms c/f metastatic involvement of spine. MRI
imaging of the back ruled this out. Most likely etiology is
musculoskeletal from strain from his abdominal ascites. His pain
was treated with PRN oxycodone and APAP.
CHRONIC ISSUES
#Gout: Pt has 2 month history of gout in R great toe. He was
asymptomatic during course. Home allopurinol was given.
#HTN: Held home Lisinopril and metoprolol
#HLD: Continued home atorvastatin
#DM2: Held oral agents, HISS
**** TRANSITIONAL ISSUES ****
# PATHOLOGY: reports pending at discharge (Pathology attendings:
Dr. ___, Dr. ___ - report to be followed up by Dr.
___ with family at visit on ___
# ASCITES: next scheduled paracentesis at ___,
___ - office will call son, ___, to confirm time/location
# BACTERIAL PERITONITIS: cultures negative; cellularity of
ascites fluid likely secondary to omental caking
# CODE STATUS: FULL
# CONTACT: Wife: ___ ___, Son: ___
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY Gout
2. Colchicine 0.6 mg PO TID PRN Gout Flare
3. Diazepam 2.5 mg PO BID PRN Anxiety
4. GlipiZIDE XL 10 mg PO DAILY DM2
5. Lisinopril 40 mg PO DAILY HTN
6. Metoprolol Succinate XL 25 mg PO DAILY HTN
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
8. Simvastatin 40 mg PO QD HLD
Discharge Medications:
1. Allopurinol ___ mg PO DAILY Gout
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
3. Simvastatin 40 mg PO QD HLD
4. Colchicine 0.6 mg PO TID PRN Gout
5. Diazepam 2.5 mg PO BID PRN Anxiety
6. GlipiZIDE XL 10 mg PO DAILY DM2
7. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice per day Disp
#*60 Tablet Refills:*0
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*28
Tablet Refills:*0
9. Senna 8.6 mg PO BID
Stop if you have cramps or diarrhea.
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*60 Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID
Stop this if you have diarrhea
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Omental caking secondary to peritoneal carcinomatosis (unknown
primary at time of discharge), ascites, bacterial peritonitis
SECONDARY DIAGNOSES:
====================
hypertension, hyperlipidemia, CKD, gout, diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
for three weeks of abdominal and back pain, as well as fluid
accumulating in your stomach. Your primary care doctor asked you
to come to the hospital after you had a CAT scan of your stomach
showing fluid and strange masses concerning for cancer.
In the hospital you had a CAT scan of your chest which showed
small nodules, which are likely benign (not cancer) but still
could be. You will need to repeat this chest CAT scan in the
future. You also had an MRI of your back which didn't show
spread of cancer to your spine. A biopsy was taken of one of the
masses from your stomach. Fluid was also drained from your
stomach to make you feel more comfortable. However, the fluid
came back very quickly so we drained it two more times. During
the second drainage, you were found to have an infection in the
fluid in your stomach called "bacterial peritonitis." You were
given antibiotics to treat it. During the third drainage, your
fluid was still abnormal. However, we think the abnormalities in
the fluid are most likely caused by the cancer, rather than an
infection. Given that you had no fever or abdominal pain w/o the
antibiotics, we were reassured that you did not have an
infection.
In order to determine where your cancer came from, you underwent
a colonoscopy, an upper endoscopy (Colonoscopy through the
mouth) and ultrasound. These tests did not show any cancers in
your stomach, esophagus, pancreas or colon.
Due to difficulty in making the diagnosis by pathology, the
biopsy was repeated. The results were pending when you left the
hospital and you should receive these at your oncology follow up
appointment (below).
It was a pleasure caring for you. We wish you the very best,
Your team at ___
Followup Instructions:
___
|
10419853-DS-14 | 10,419,853 | 28,779,766 | DS | 14 | 2143-06-12 00:00:00 | 2143-06-13 08:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
Lumbar puncture ___
attach
Pertinent Results:
ADMISSION LABS
===============
___ 12:40AM BLOOD WBC-11.2* RBC-4.16 Hgb-12.9 Hct-38.1
MCV-92 MCH-31.0 MCHC-33.9 RDW-12.2 RDWSD-40.8 Plt ___
___ 12:40AM BLOOD Neuts-89.3* Lymphs-5.7* Monos-4.5*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.97* AbsLymp-0.63*
AbsMono-0.50 AbsEos-0.00* AbsBaso-0.01
___ 12:40AM BLOOD Plt ___
___ 01:50AM BLOOD Glucose-72 UreaN-6 Creat-0.5 Na-137 K-3.9
Cl-105 HCO3-16* AnGap-16
___ 01:50AM BLOOD ALT-9 AST-17 AlkPhos-33* TotBili-0.5
___ 01:50AM BLOOD Albumin-3.9
___ 01:50AM BLOOD Osmolal-277 Beta-OH-2.6*
OTHER PERTINENT LABS
=====================
___ 05:23AM BLOOD Lyme Ab- PEND
___ 05:23AM BLOOD HIV Ab-NEG, Trep Ab-NEG
___ 5:40 am SEROLOGY/BLOOD
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
(Reference Range-Negative).
___ 10:21 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 1:12 am CSF;SPINAL FLUID
ADDON VIRAL CULTURE PER ___ (___) ___.
Enterovirus Culture (Preliminary): No Enterovirus
isolated.
___ 1:12 am CSF;SPINAL FLUID TUBE 3.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Preliminary): NO GROWTH.
___ 12:03 am THROAT FOR STREP
**FINAL REPORT ___
R/O Beta Strep Group A (Final ___:
NO BETA STREPTOCOCCUS GROUP A FOUND.
Herpes Simplex Virus, PCR, CSF
Received: ___ 15:19 Reported: ___ ___
MCR
Reference Value
Negative
HSV 1 PCR, C
Negative
IMAGING
========
CXR ___:
The lungs are well expanded and clear. No pleural effusion or
pneumothorax.
Heart size is normal. The mediastinal and hilar contours are
unremarkable.
DISCHARGE LABS
===============
___ 09:35AM BLOOD WBC-3.0* RBC-3.85* Hgb-11.6 Hct-35.6
MCV-93 MCH-30.1 MCHC-32.6 RDW-12.2 RDWSD-41.5 Plt ___
___ 09:35AM BLOOD Neuts-69 Lymphs-18* Monos-7 Eos-4 Baso-0
Atyps-2* AbsNeut-2.07 AbsLymp-0.60* AbsMono-0.21 AbsEos-0.12
AbsBaso-0.00*
___ 05:40AM BLOOD Glucose-91 UreaN-7 Creat-0.5 Na-141 K-4.0
Cl-106 HCO3-22 AnGap-13
___ 06:17PM BLOOD ALT-10 AST-16 AlkPhos-36 TotBili-<0.2
___ 05:40AM BLOOD Calcium-9.0 Phos-5.3* Mg-1.9
Brief Hospital Course:
TRANSITIONAL ISSUES
====================
[] f/u PCP for headache and nausea symptoms
[] make sure patient up to date with meningitis vaccine series
[] would be helpful to find out bacterial meningitis pathogen
from her past
___ is a ___ yo F with significant past medical history with
prior dx of bacterial meningitis who presents with fever and
headache concerning for viral meningitis.
ACUTE/ACTIVE ISSUES:
====================
# Viral meningitis
# Headache/fever:
Patient with multiple day history of ongoing headache and
nausea. DDx included migraine although not amendable to typical
migraine medications and migraine alone would not cause
fevers/leukocytosis. More likely diagnosis is viral meningitis
with CSF studies showing 14 cells, 89% lymphs (glucose 43,
protein 30) iso viral prodrome with URI symptoms. Encephalitis
less likely given patient ___ awake and alert on exam with no
changes in mental status, and CSF HSV negative. HIV, trep Ab,
flu negative, CSF gram stain, CSF enterovirus, throat strep
culture negative. Continued IV ceftriaxone/vancomycin for 48
hours given clinical improvement but given low concern for
bacterial meningitis stopped Vanc ___. Stopped acyclovir ___
given low concern for HSV encephalitis. Continued Tylenol as
needed and encouraged po intake. Well-appearing and so stable
for d/c ___, however lyme Ab still pending. Started on
doxycycline w/ plan to call and have pt d/c if lyme comes back
negative.
RESOLVED ISSUES:
=================
# Leukocytosis:
Mild leukocytosis is likely secondary to possible
meningitis/encephalitis infection vs. stress vs. pain induced.
Resolved
# Anion gap metabolic acidosis:
Etiology is unknown at this time but could be secondary to
lactate vs. ketones with ketones in urine from starvation (BG is
within normal range and no hx of DM) and ketones in blood
(elevated betahydroxybutyrate) vs. medication induced but
nothing obvious on medication list and no hx of ingestions. s/p
fluids, normal lactate. Resolved
# Ketonuria
# Elevated beta hydroxbutyrate:
Patient with UA negative besides from 150 ketones which is
concerning for possible starvation ketosis but patient reports
normal diet and no hx of eating disorders. No history of DM and
BG normal on laboratory test. Pt only reports occasional alcohol
use. s/p IVF. Resolved.
# Chest pain:
Likely secondary to viral cough/congestion with some upper
airway irritation vs. possible stress/anxiety. Very low
suspicion for ACS or cardiac cause of chest pain given her age
and no known risk factors. Most likely etiology is MSK.
Resolved.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 14 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*28 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Viral meningitis
SECONDARY DIAGNOSES
====================
Upper respiratory infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___,
WHY YOU WERE HERE
- You were having a headache and fevers
WHAT WE DID FOR YOU
- You had many blood tests and a lumbar puncture that showed
concern for viral meningitis likely secondary to a cold
- You were started empirically on antibiotics but they were
stopped once we were confident this was a viral, not a
bacterial, infection
WHAT YOU SHOULD DO WHEN YOU LEAVE
- Please follow up with your primary care doctor
- You should continue the doxycycline for 14 days, or until you
hear back from one of your doctors here to let you know about
the lyme antibodies.
- Please call your doctor or come back to the ER for any
concerning symptoms including worsening headache, neck
pain/stiffness, fevers, blurry vision, weakness, paresthesias
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10420250-DS-5 | 10,420,250 | 26,008,424 | DS | 5 | 2140-06-11 00:00:00 | 2140-06-11 20:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
acute onset right sided weakness and dysarthria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old man with history of
hypertension, IDDM2 who presents with acute onset right sided
weakness and dysarthria.
The patient reports that he was in his usual state of health
today into the evening. He presented for his night shift work
around ___. At around 7PM, he went to the bathroom. While he
was reaching for the toilet paper, he noticed he could not move
his right hand. He had difficulty with moving the entire right
arm at this point. He thought it odd, but was able to finish his
business with his left hand. He denied any headaches at this
time. He was able to stand from the toilet, but again because of
the right arm weakness he was unable to pull up his pants. He
used his left arm for this. He was able to walk out of the
bathroom into the hallway, and seconds-minutes later felt like
his right leg was weak as well, and needed to brace himself
against the wall to avoid falling. He did not fall or strike his
head at this time. He called for help, and did not notice any
issues with words, although he noticed it sounded slurred. His
friend arrived at this time, and was able to sit him down on a
nearby chair. EMS was called and the patient was transferred to
___.
Past Medical History:
HTN
IDDM2
Distant history of Bell's palsy ___ years ago) on left side of
face
Social History:
___
Family History:
no history of CVA
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: T: afebrile HR: ___ BP: 144/90-175/80 RR: 18 SaO2:
100% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to person, time, and
place. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Speech is fluent
with full sentences, intact repetition, and intact verbal
comprehension. Naming intact, limited slightly by language
barrier (did not know what hammock was). No paraphasias.
Mild-moderate dysarthria. Normal prosody. No apraxia. No
evidence of hemineglect. No left-right confusion. Able to follow
both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. Right facial droop. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor: Normal bulk and tone. LUE and LLE full. RUE fluctuated
between flaccid (initial encounter), to antigravity effort at
the deltoid. No appreciable movement of the distal arm, wrist,
and fingers. RLE initially able to wriggle toes only, but in 30
minutes able to sustain 4+ at IP, 5 at quad, 4+ at hams, 4+ at
TA, 5 at gastrocs, and 5 at ___.
- Reflexes: 1s throughout, absent at ankles. Toes mute
bilaterally.
- Sensory: No deficits to light touch, pin throughout. Mildly
decreased proprioception bilaterally to fine movements of the
great toes. No extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally on left, unable to perform on right.
- Gait: deferred
DISCHARGE PHYSICAL EXAM:
========================
VS: T98.4 119 / 62 58 20 97 Ra
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: non-labored breathing
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to person, place, month
and year. Able to relate history and name ___ without
difficulty. Speech is fluent with full sentences and intact
verbal comprehension, but there is mild dysarthria.
- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. Minimal loss of pinprick sensation in R nasolabial
region (90% compared to left). R lower facial droop, improved
from yesterday. Hearing intact to finger rub bilaterally.
Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline.
- Motor: Normal bulk and tone throughout. No tremor or
asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 3 3 4 0 0 0 4 4 3 0 5 0
*of note, RUE and RLE motor does fluctuate in weakness*
Bilateral neutral plantar response
- Sensory: No deficits to light touch bilaterally. Minimal loss
of pinprick sensation in R nasolabial region (90% compared to
left), unchanged from yesterday. Loss of pinprick sensation on
bilateral lower extremities up to mid-shin, R>L. Diminished
proprioception on bilateral great toe. No extinction to DSS.
- Coordination: No dysmetria with FNF on L, unable to perform on
right.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:26PM URINE HOURS-RANDOM
___ 10:26PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 10:26PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-70* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:26PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:16PM GLUCOSE-222* NA+-139 K+-4.1 CL--103 TCO2-22
___ 08:10PM CREAT-0.9
___ 08:10PM GLUCOSE-226* UREA N-22* CREAT-0.9 SODIUM-140
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-21* ANION GAP-17*
___ 08:10PM estGFR-Using this
___ 08:10PM estGFR-Using this
___ 08:10PM ALT(SGPT)-13 AST(SGOT)-18 ALK PHOS-89 TOT
BILI-0.4
___ 08:10PM cTropnT-0.01
___ 08:10PM ALBUMIN-4.2 CALCIUM-9.2 PHOSPHATE-3.2
MAGNESIUM-2.1
___ 08:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:10PM WBC-7.1 RBC-5.04 HGB-13.8 HCT-41.7 MCV-83
MCH-27.4 MCHC-33.1 RDW-12.2 RDWSD-36.5
___ 08:10PM PLT COUNT-238
___ 08:10PM ___ PTT-28.0 ___
IMAGING:
========
___ MR Head: Slight increase in size of the acute
intraparenchymal hemorrhage centered within the left corona
radiata just lateral to the left thalamus; The hemorrhage
results
in slight mass effect on the left lateral ventricle
with a minimal midline shift to the right, measuring 2 mm;
Allowing for motion artifact, no definite enhancement on
postcontrast images is identified within the hemorrhage; Minimal
T2/FLAIR white matter hyperintensities are nonspecific but can
be
seen with chronic small vessel disease; Mild generalized
parenchymal volume loss, likely age related.
___ CTA Head and Neck: Small acute intraparenchymal hemorrhage
centered in the left corona radiata resulting in mild mass
effect
on the left lateral ventricle. No associated
mass or vascular malformation is identified; Severe focal
narrowing of the distal left PCA P1 segment; Decreased caliber
and irregularity of the right PCA P1 segment is likely
secondary to atherosclerotic disease; No evidence of dissection
or aneurysm formation.
___ CT HEAD
There is 1.6 cm x 1.5 cm acute hematoma centered on posterior
left putamen, extending into the posterior limb left internal
capsule and corona radiata, with moderate surrounding edema.
Hematoma size is stable compared with ___, surrounding
edema is mildly more prominent. There is no intraventricular
extension. No significant midline shift. No hydrocephalus.
There is no evidence of new infarction,hemorrhage,edema, or
mass. There is mild generalized brain parenchymal atrophy.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable. Stable
1.6 cm parenchymal hematoma centered on posterior left putamen.
INTERVAL LABS:
==============
___ 06:55AM BLOOD %HbA1c-9.0* eAG-212*
___ 06:55AM BLOOD TSH-1.6
___ 06:55AM BLOOD Triglyc-94 HDL-40* CHOL/HD-4.4
LDLcalc-116
Brief Hospital Course:
Mr. ___ ___ man with history of hypertension,
IDDM2 who presented with acute onset right sided weakness and
dysarthria, exam notable for R hemiparesis, found to have an
intraparencyhmal hemorrhage in the L corona radiata lateral to
the thalamus.
#Left IPH of corona radiata
1.7 x 1.5cm hemorrhage resulting in mild mass effect on the left
lateral ventricle seen on admission CT with slight interval
increase on subsequent MRI. The location of the hemorrhage
readily explains the patient's presenting symptoms and is most
consistent with a hypertensive etiology, further evidenced by
his history of HTN and the fact that his BPs were difficult to
control while inpatient. To that end, we increased his
Lisinopril dose to 10mg daily (previously 5mg daily) and started
him on Labetalol 200mg BID to maintain SBP<150. We further
recommended that he start taking a statin to lower his
cholesterol and LDL, but we discussed this with the patient and
his preference is to try dietary and lifestyle modifications,
which is okay for now, provided that this is closely followed up
on. Throughout his stay, his symptoms were fluctuating with
periods of improvement and worsening. A repeat NCHCT revealed no
change in the size of his bleed. Other possible etiologies which
would be hard to appreciate on current imaging include cavernous
angioma and underlying mass (felt to be unlikely)- these should
be further investigated with outpatient MRI in six weeks. The
patient was seen by ___ who recommended discharge to
rehabilitation program.
#Insulin-dependent DM Type II
Patient had HbA1c 9.0 on admission. ___ was consulted and
recommended the following changes to his insulin regimen:
increased bedtime Lantus to 40U, increased mealtime Humalog to
8U, and introduced mealtime and bedtime Humalog sliding scale as
per below. He was provided education through the diabetes
educator.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
TRANSITIONAL ISSUES:
========================
New/Changed Medications:
1. Lisinopril dose increased from 5 mg daily to 10mg PO daily
2. Labetalol 200mg PO BID
3. see discharge medications for insulin regimen
[] F/u blood pressure, normotensive (sbp<150 ok in the acute
settting). Consider transition off labetalol and to amlodipine
vs. thiazide diuretic if long term blood pressure medication is
needed. Can consider increasing lisinopril or increasing
labetolol frequency if blood pressure is elevated.
[] F/u MRI in 6 weeks to assess for underlying cause of
hemorrhagic stroke
[] Patient will try dietary and lifestyle modifications rather
can pharmacotherapy to lower his cholesterol and LDL. Please
follow-up on this when you see him in clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Lantus (insulin glargine) 56 U subcutaneous QPM
3. HumaLOG (insulin lispro) ___ U subcutaneous TID W/MEALS
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC BID
5. Glargine 40 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Labetalol 200 mg PO BID
7. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute hemorrhagic stroke
Hypertension
Insulin-dependent Diabetes Mellitus, Type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of right arm and leg
weakness and slurred speech resulting from an ACUTE HEMORRHAGIC
STROKE, a condition where there is bleeding in your brain from a
blood vessel that usually provides it with oxygen and nutrients.
The brain is the part of your body that controls and directs all
the other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms. In your case, the bleeding occurred in a part of the
brain that controls movements of your limbs.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1. Hypertension (high blood pressure)
2. Diabetes Mellitus
We are changing your medications as follows:
**INCREASE Lisinopril 10mg daily
**START Labetalol 200mg PO BID
There are changes to your diabetes regimen. Please see your
medication list for details.
Please follow up with Neurology and your primary care physician
as listed below. As part of your follow-up, you will undergo a
repeat MRI of your brain in about 6 weeks (once the blood has
been reabsorbed) to look for other possible underlying causes of
your stroke.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10420269-DS-8 | 10,420,269 | 21,127,521 | DS | 8 | 2145-01-13 00:00:00 | 2145-01-14 05:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Combined case:
Cystoscopy/L retrograde pyelography/L ureteral stent placement-
Dr. ___- ___
Incisional ventral hernia repair- Dr. ___ - ___
History of Present Illness:
Mrs ___ is a ___ woman with a history of hypertension
hyperlipidemia hypothyroidism and a history of remote
hysterectomy, likely abdominal adhesions status post lysis, who
presents for evaluation of nausea, vomiting, and abdominal pain.
Patient reports being in her usual state of health until this
morning, when around 8 AM, she had the relatively sudden onset
of
moderate to severe intensity left lower quadrant abdominal pain.
She has been nauseous but has not vomited. she came to the
emergency department here for further evaluation. She had an
episode of vomiting upon arriving to the emergency department.
She has had chills. No chest pain or shortness of breath. No
urinary symptoms. No other symptoms to.
Past Medical History:
Obstructive Sleep Apnea
Gout
GERD
Total Abdominal Hysterectomy
SBR
LOA
Social History:
___
Family History:
non-contributory
Physical Exam:
Based on OMR ___ note:
OBJECTIVE:
Vitals: 24 HR Data (last updated ___ @ 634)
Temp: 98.9 (Tm 98.9), BP: 111/70 (97-135/60-81), HR: 82
(68-82), RR: 18 (___), O2 sat: 93% (91-99), O2 delivery: Ra
(1L-3L), Wt: 0174.3 lb/79.06 kg
Fluid Balance (last updated ___ @ 509)
Last 8 hours Total cumulative 727ml
IN: Total 1027ml, IV Amt Infused 1027ml
OUT: Total 300ml, Urine Amt 300ml
Last 24 hours Total cumulative 727ml
IN: Total 1027ml, IV Amt Infused 1027ml
OUT: Total 300ml, Urine Amt 300ml
Physical exam:
Gen: NAD, lying comfortably in bed
Card: RRR,
Pulm: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended, normal bs.
Wounds: c/d/i
Ext: No edema, warm well-perfused
Pertinent Results:
___ 05:55AM BLOOD WBC-8.7 RBC-3.86* Hgb-10.6* Hct-35.5
MCV-92 MCH-27.5 MCHC-29.9* RDW-13.5 RDWSD-45.3 Plt ___
___ 06:20AM BLOOD WBC-10.4* RBC-4.36 Hgb-12.0 Hct-39.7
MCV-91 MCH-27.5 MCHC-30.2* RDW-13.4 RDWSD-44.9 Plt ___
___ 06:10AM BLOOD WBC-10.4* RBC-4.23 Hgb-11.6 Hct-38.4
MCV-91 MCH-27.4 MCHC-30.2* RDW-13.2 RDWSD-44.2 Plt ___
___ 04:53PM BLOOD WBC-10.4* RBC-4.76 Hgb-13.0 Hct-42.2
MCV-89 MCH-27.3 MCHC-30.8* RDW-13.1 RDWSD-42.6 Plt ___
___ 06:10AM BLOOD Neuts-63.3 ___ Monos-7.0 Eos-0.5*
Baso-0.3 Im ___ AbsNeut-6.61* AbsLymp-2.96 AbsMono-0.73
AbsEos-0.05 AbsBaso-0.03
___ 04:53PM BLOOD Neuts-82.5* Lymphs-12.6* Monos-4.3*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.58* AbsLymp-1.31
AbsMono-0.45 AbsEos-0.01* AbsBaso-0.02
___ 05:55AM BLOOD Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___ PTT-29.6 ___
___ 04:53PM BLOOD Plt ___
___ 05:55AM BLOOD Glucose-74 UreaN-15 Creat-0.8 Na-145
K-4.1 Cl-107 HCO3-23 AnGap-15
___ 06:20AM BLOOD Glucose-66* UreaN-15 Creat-0.8 Na-143
K-3.7 Cl-108 HCO3-18* AnGap-17
___ 06:10AM BLOOD Glucose-93 UreaN-11 Creat-0.8 Na-143
K-4.2 Cl-110* HCO3-23 AnGap-10
___ 04:53PM BLOOD Glucose-104* UreaN-11 Creat-0.8 Na-143
K-3.7 Cl-102 HCO3-26 AnGap-15
___ 04:53PM BLOOD ALT-16 AST-19 AlkPhos-93 TotBili-0.5
___ 06:20AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0
___ 06:10AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.2
___ 08:16PM BLOOD Lactate-0.9
Brief Hospital Course:
Ms. ___ was admitted on ___ under the acute care surgery
service for management an incisional hernia repair. On further
images it was noted she also had a left ureteral stone
obstruction. She was taken to the operating room and underwent
an incisional hernia repair and left ureter stent placement
combined case with the ACS surgery and Urology services. Please
see operative report for details of this procedure. She
tolerated the procedure well and was extubated upon completion.
She was subsequently taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic with Dr. ___.
Medications on Admission:
1. amLODIPine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Pramipexole 0.375 mg PO QHS:PRN restless legs
8. Rosuvastatin Calcium 40 mg PO QPM
9. TraMADol 50 mg PO BID:PRN Pain - Moderate
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*6 Tablet Refills:*0
9. Pramipexole 0.375 mg PO QHS:PRN restless legs
10. Rosuvastatin Calcium 40 mg PO QPM
11. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
12. TraMADol 50 mg PO BID:PRN Pain - Moderate
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
- L ureteral obstruction
- Incisional ventral hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ and
underwent an incisional hernia repair and left ureter stent
placement. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. o Your incisions may be slightly red around the
stitches. This is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10420453-DS-16 | 10,420,453 | 29,130,685 | DS | 16 | 2114-12-06 00:00:00 | 2114-12-06 21:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLQ pain and LLE pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo M with a PMHx of stage IV prostate cancer with
L4 vertebral disease as well as extensive retroperitoneal and
pelvic lymphadenopathy who is s/p androgen deprivation therapy
and XRT to the L-3 and prostate c/b placement of a left sided
nephrostomy tube recently for decompression due to
distal ureteral obstruction likely from compression who p/w LLQ
abominal pain and LLE pain.
The patient reports having intermitent LLQ pain for years that
was self limited and mild. The patient went away follow XRT
treatment from ___ to ___. The pain then came back 3 weeks
ago and was a ___ in nature and described as a constant
throb. He was Dr. ___ of a recent increase in pain
and following this visit was unable to sleep so presented to the
ED. The patietn has been passing flatus and has BM's Q2-3 days.
Denies blood in stool. He has had a recent onset of
constipation while starting his new chemotherapy. He also has a
h/o diverticula on a colonoscopy done at an OSH. His history is
also notable for left sided hydouterter, which was asymptomatic.
He has no h/o stones and denies hematuria.
The patient also acknowledged LLE pain for months and it has
gotten slightly worse over time. He has had no issues with
ambulating. Denies falls, parathesias or saddle anesthesia. He
c/o mild urinary leakage which is new. He describes the pain as
on the posterior and lateral portion of his left leg extending
down to ankle. He has had similar pain that is releived by XRT
to his back. Denies h/o disc herniation.
In the ED, the patients Vs were stable. The patient was
evalauted by Neurology who did not feel as though an emergent
MRI was necessary. The patient got a CT of his abdomen and was
sent to the floor. His LLE pain was relieved by gabapentin.
10 point ROS is positive mild exertional dyspnea, otherwise is
negative
Past Medical History:
ONCOLOGICAL HISTORY: Mr ___ is a ___ year old male who
presented with painless hematuria in ___. He was advise to
undergo cystoscopy at that time, but declined. He had another
episode of hematuria in ___ with passage of clots.
Digital rectal exam revealed a firm left lobe of the prostate.
PSA was 5.19. The prostate was biopsied in ___, (PSA
11.76) showing the following: right lobe ___ 3+3 in ___
cores, 5% of tissue; left lobe ___ 5+5 involving 7 out of 7
cores, ~20% of tissue, lymphovascular invasion noted. This was
performed at ___ with Dr ___.
Further staging studies done at that time showed evidence of
metastatic disease. CT scan of the abdomen and pelvis showed L4
vertebral disease as well as extensive retroperitoneal and
pelvic
lymphadenopathy. He was then started on Casodex and Zoladex 1
month injection around ___. He had PSA good response
when
reassessed in ___ with evidence of PSA drop to 0.48 in
___. Casodex was stopped around that time. He continued
to
do rather well until a few months later when he complained of
hematuria and constant lower back pain and abdominal pain. PSA
in
___ was found to be elevated at 10.15. He then underwent
radiation therapy to the back and pelvis while on androgen
deprivation therapy at ___ with Dr ___. Per
review of Dr ___, the L3-sacral area was treated using
area was treated using a 3-field approach with CT planning and
computerized dosimetry and received 3600 cGy in 12 fractions
from
___ through ___. The prostate was treated using IMRT
with CT planning and
computerized dosimetry and received 6000 cGy in 30 fractions
from
___ through ___, again with CT planning and
computerized dosimetry. Cone beam CT was used for daily
positioning. He had rapid resolution of his pain, which had
resolved after his second week of treatment to that area. By the
third week of radiation to the prostate, he had resolution of
the
bleeding. He attained good PSA response with PSA lowered to 0.78
in ___. He was instructed to restart Casodex and started
finasteride at that time.
His first visit at the ___ Prostate Cancer clinic was on
___. Initial thought was for him to be on the MDV3100
androgen receptor antagonist trial involving its use in
chemo-naive patients (PREVAIL: A Multinational Phase 3,
Randomized, Double-Blind, Placebo-Controlled Efficacy and Safety
Study of Oral MDV3100 in Chemotherapy-Naïve Patients with
Progressive Metastatic Prostate Cancer Who Have Failed Androgen
Deprivation Therapy). However, he did not meet eligibility
requirements due to his history of radiation therapy to his
vertebrae prior to enrollment. For notation, his last dose of
bicalutamide and finasteride taken by the patient was on
___.
The patient was offered and agreed to participate in the
following trial: ___ Phase I/II Trial of Ketoconazole,
Hydrocortisone, Dutasteride, and Lapatanib (KHAD-L) in
Castration-Resistant Prostate Cancer with Pre- and Post-Therapy
Tumor Biopsies.
___ - Start date; C1 D1
TREATMENT HISTORY:
First Line Regimen - ADT, started ___
Radiation therapy - ___ - ___
Second Line Regimen - KHAD-L study; started ___ - visit; bone biopsy performed today, started lapatinib
___ - visit; ___ bone biopsy performed today, C2 lapatinib
___ - visit; C3 lapatinib
___ - visit; C4 lapatinib
___ - visit; C5 lapatinib
___ d/c from lapatinib trial due to progression of disease
Third Line Regimen - abiraterone 1000 mg daily (+ prednisone 5
mg
po bid) started ___
-nephrostomy tube placed on ___ for hydroureter Left side.
-no major issues since then
PAST MEDICAL HISTORY:
1. Repaired uretheral stricture in ___
2. Prostate Cancer
3. Rectal polyp, removed ___
4. HTN -d/c HCTZ 3 weeks ago
Social History:
___
Family History:
Mother - breast cancer, died age ___
No other known history of maligancy
Has two grown sons.
Physical Exam:
ADMISSION EXAM:
VS: 98.6 ___ 99 RA
General: AAOX3, in NAD
HEENT: OP clear, MMM
CV: RRR, no RMG
Lungs: CTAB, no WRR
Abdomen: NTND, active BS X4 quadrants, no HSM
Extremities: WWP, no edema, 2+ pulses are equal
Neuro: Strength, sensation, CN's and MS wnl, ___ reflexes
1+ and equal, SLR negative
Psyc: mood and affect wnl
Derm: no obvious rashes
DISCHARGE EXAM:
Abdomen: soft, non tender, non distended, positive bowel sounds,
no organomegaly appreciated
Extremities: warm and well perfused
Neurology: gait within normal limits, sensation grossly intact,
strength ___ throughout, patellar and achiles reflexes 1+ but
symmetric, CN2-12 intact.
Pertinent Results:
___ 11:55AM BLOOD WBC-6.7 RBC-3.84* Hgb-10.2* Hct-32.2*
MCV-84 MCH-26.5* MCHC-31.6 RDW-16.4* Plt ___
___ 11:55AM BLOOD Neuts-80.8* Lymphs-12.5* Monos-4.1
Eos-2.0 Baso-0.5
___ 11:55AM BLOOD ___ PTT-27.8 ___
___ 11:55AM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-140
K-3.8 Cl-105 HCO3-24 AnGap-15
___ 08:05AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.2
___ 12:14PM BLOOD Lactate-1.4
___ 08:05AM BLOOD WBC-4.7 RBC-3.70* Hgb-9.9* Hct-31.0*
MCV-84 MCH-26.7* MCHC-31.8 RDW-16.5* Plt ___
___ 05:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
CT abdomen and pelvis: Bilateral lung bases show dependent
atelectasis, otherwise no effusions, masses, or nodules are
noted. Two segment II hypodense liver lesions measuring up to 1
cm likely represent cysts or hemangiomas. The gallbladder,
spleen, and pancreas are all unremarkable. Bilateral adrenal
glands are normal appearing. The kidneys enhance and excrete
contrast symmetrically with no evidence of hydronephrosis. There
is a left-sided percutaneous nephrostomy tube in appropriate
position within the renal pelvis. Hydronephrosis has resolved.
Multiple retroperitoneal nodes are again noted, the largest of
which measures 3.2 x 2.8 cm (previously 2.5 x 1.9 cm) adjacent
to the left renal pelvis (2:34). The aorta shows mild vascular
calcification throughout its course. Stomach and small and large
loops of bowel are unremarkable. CT OF THE PELVIS: The patient
has known prostatic carcinoma. The bladder demonstrates
asymmetric wall thickening(2:66) greater on the left.
Softtissue attenuation and stranding impresses upon the left
bladder dome (2:63) and has progressed. This lies immediately
subjacent to the colon. Rectosigmoid colon shows numerous
diverticula. Several enlarged pelvic and inguinal nodes have
enlarged, most notably a right-sided inguinal node measuring 2.8
x 1.9 cm (previously 1.6 x 1.1 cm). OSSEOUS STRUCTURES:
Sclerosis of the L4 vertebral body as well as left sided wedge
compression fracture is unchanged. 2.0 x 1.4 cm lytic lesion in
the left iliac bone extending into the SI joint is stable. Also
stable is sclerosis within the left iliac wing. No new osseous
lesions are noted.
IMPRESSION: 1. Increased soft tissue density and stranding
situated between the left bladder dome and sigmoid colon.
Differential diagnosis includes extension of tumor, nonspecific
inflammation, and focal diverticulitis. 2. Interval progression
of metastatic disease. 3. Stable pathologic L4 compression
fracture.
MRI L spine: MR L-SPINE: There is no spinal cord compression.
Again seen is compression deformity of the left L4 vertebral
body, unchanged from one day prior. Otherwise, vertebral body
heights are maintained. The conus medullaris ends at T12-L1.
No cord signal abnormality is seen. There is heterogeneity in
the lower thoracic spine to the level of L2, which
may be due to bone marrow infiltration. Increased T1 signal
from L3 through S3 may be sequelae of radiation change.
Increased T2 heterogeneity in L4 may represent a combination of
metastatic disease and treatment effect. Enhancing lesions are
seen in the L5 vertebral body extending into the pedicle as well
as the left S1 vertebral body and the left iliac wing. The
metastatic lesions do not impinge on the spinal cord or nerve
roots. After contrast administration, there is no abnormal
leptomeningeal or abnormal vascular enhancement. At T12-L1,
L1-L2 and L2-L3, there is mild disc bulge without significant
spinal canal or neural foraminal narrowing. At L3-L4, there is
right lateral disc bulge and mild facet arthropathy. These
narrow the right neural foramen without nerve root impingement.
The spinal canal is not narrowed at this level. At L4-L5, there
is disc bulge, right more than left, with facet arthropathy.
These narrow the right neural foramen, impinging the exiting L4
nerve root. There is no significant spinal canal narrowing at
this level. At L5-S1, there is mild disc bulge and mild facet
arthropathy without spinal
canal or neural foraminal narrowing.
IMPRESSION: 1. No cord compression. 2. Metastatic foci in the
L4, L5, and S1 vertebral bodies as well as the left iliac wing
without spinal canal or nerve root impingement. Unchanged
compression deformity of the left L4 vertebral body. No evidence
of leptomeningeal metastases.
3. Degenerative change as described above. A combination of
disc bulge and facet arthropathy impinges the exiting right L4
nerve root within the neural
Brief Hospital Course:
___ male with history of stage IV prostate cancer s/p
XRT in clinical trial (abiraterone 1000 mg daily + prednisone 5
mg po bid) started ___ c/b left sided hydroureter and
nephrostomy tube placed on ___ who now p/w LLQ pain with a
normal WBC and LLE pain and subacute weakness with a CT that
showed increased soft tissue density and stranding situated
between the left bladder dome and sigmoid colon.
Acute Problems:
# Left lower extremity pain: The most likely etiology is
radicular pain given the MRI with L4 nerve root compression.
There is no spinal cord compression and this seems to be
secondary to disc herniation and degenerative disk disease
rather than metastatic disease (although present in the MRI). He
was given oxycodone and neurontin with complete relief of the
lower extremity pain. He was able to ambulate without difficult.
He was discharged with primary care follow up. He may need
physical therapy for further treatment.
# Left lower quadrant pain: The etiology is not entirely clear.
He had a CT with soft tissue density and stranding in between
the left bladder done and sigmoid colon. The differential was
tumor, vs diverticulitis, vs other inflammation. He did not have
leukocytosis, fevers or any real signs of infection. We gave 7
days of ciprofloxacin and flagyl with a plan to repeat abdominal
imaging in a few weeks. If the area is still present it is more
likely cancer than secondary to diverticulitis. Also, the
patient has follow up with Dr. ___ a cystoscopy to
evaluate the bladder for any evidence of tumor. Dr. ___ was
contacted and will order follow up imaging. On discharge he was
completely pain free.
Chronic Problems:
# Stage IV prostate cancer: He was continued on his home
regimen.
# normocytic anemia: He had no evidence of bleeding.
# Hypertension: Currently on no antihypertensives. Will follow
up with primary care physician.
Transitional Issues:
- follow up abdominal imaging
- may need physical therapy for radiculopathy
Medications on Admission:
ABIRATERONE [ZYTIGA] - 250 mg Tablet - 4 Tablet(s) by mouth once
a day (1000 mg daily dose)
ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - 1 Tablet(s) by
mouth every four (4) hours
GOSERELIN [ZOLADEX] - (Prescribed by Other Provider) - Dosage
uncertain
PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day
Medications - OTC
ACETAMINOPHEN [TYLENOL] - (OTC) - 325 mg Tablet - 2 Tablet(s)
by
mouth three times a day as needed for pain
CALCIUM CARBONATE [TUMS] - (OTC) - Dosage uncertain
Discharge Medications:
1. Zytiga 250 mg Tablet Sig: Four (4) Tablet PO QD ().
2. calcium Oral
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Zoladex Subcutaneous
5. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for pain: do not drive or operate heavy
machinery with this med.
Disp:*30 Capsule(s)* Refills:*0*
6. Neurontin 100 mg Capsule Sig: One (1) Capsule PO three times
a day: This medication may make you drowsy, discuss with PCP.
Disp:*90 Capsule(s)* Refills:*0*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
10. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Abdominal pain
Disc protusion with radiculopathy
Secondary Diagnosis:
Prostate cancer
Nephrostomy tube
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for abdominal pain and left leg pain. The
cause of your abdominal pain is not entirely clear. You had a CT
scan of your abdomen which showed a small area which may be
cancer, inflammation or diverticulitis. You were treated with
antibiotics (ciprofloxacin and metronidazole). You will need to
continue these for 7 days. You should have a repeat CT scan of
your abdomen in a couple of weeks ___ weeks). You will have
this set up with your primary care physician, ___.
The leg pain is most consistent with a disc bulge (as seen on
MRI), which is irritating the nerve root. This is best treated
with pain medication and physical therapy. I will leave this up
to your primary care physician to prescribe.
You had an MRI of your spine to evaluate your leg pain. Based on
a preliminary report, the pain is likely due to the disc
protusion. We do need to await the final read of your back prior
making final conclusions. This report will be sent to Dr.
___ Dr. ___ will have access as well. Please discuss
the final results with them.
The following changes were made in your medications:
1. STOP: acetaminophen-codeine
2. START: oxycodone
3. START: Neurontin
4. START: Ciprofloxacin for 7 days
5. START: Flagyl for 7 days
Followup Instructions:
___
|
10420500-DS-20 | 10,420,500 | 28,675,927 | DS | 20 | 2169-10-15 00:00:00 | 2169-10-15 18:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female who lives in assisted living. She states
that she got up, felt like fainting, then fainted and fell.
Notes
from her facility combined with EMS report also note that she
might have had some saliva/vomiting and that she was brought
back
to bed then brought to ___ 2 hours later. She underwent a
pan-scan that showed a rib fracture and was transferred here.
She
has dementia and is unsure of her past medical history. She
denies any pain, including denying rib pain. No dyspnea
Past Medical History:
HTN, HLD, atrial fibrillation, dementia
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM ___
VS: 96.7, 66, 138/89, 22, 94% RA
Gen: NAD
HEENT: no abrasions
Neuro: GCS 15, CN intact, moving all extremities
CV: RRR
Pulm: b/l breath sounds
Abd: no scars. soft, nondistended, nontender.
Ext: old scar on toe. b/l palpable DP.
Back: no spinal tenderness, no step offs. some right lower rib
tenderness.
DISCHARGE PHYSICAL EXAM
Vitals: 96.8 PO 133 / 80 70 16 96 ra
General: a&Ox1 to person, NAD, sleeping
HEENT: nc/at
Neck: supple, JVP not elevated
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, no edema
Neuro: A&Ox1, SILT
Pertinent Results:
___ 06:50AM BLOOD WBC-7.2 RBC-4.30 Hgb-12.1 Hct-38.0 MCV-88
MCH-28.1 MCHC-31.8* RDW-15.0 RDWSD-48.3* Plt ___
___ 06:50AM BLOOD Neuts-60.8 ___ Monos-10.0 Eos-2.8
Baso-0.4 Im ___ AbsNeut-4.38 AbsLymp-1.82 AbsMono-0.72
AbsEos-0.20 AbsBaso-0.03
___ 06:56AM BLOOD ___ PTT-35.6 ___
___ 06:50AM BLOOD Glucose-86 UreaN-23* Creat-0.8 Na-144
K-4.5 Cl-107 HCO3-24 AnGap-13
___ 06:50AM BLOOD CK(CPK)-89
___ 06:56AM ___ PTT-35.6 ___
___: chest x-ray:
No previous images. There are low lung volumes. Cardiac
silhouette is mildly enlarged and there is marked tortuosity of
the descending thoracic aorta. No definite vascular congestion
or acute focal pneumonia. Specifically, the rib fracture a
apparently seen on the outside CT is not appreciated on plain
radiographs. Specifically, no evidence of pneumothorax.
Telemetry Monitoring: Unremarkable
Brief Hospital Course:
___ year old female admitted to an outside hospital after a
un-witnessed fall. The patient was reportedly getting out of
bed to bathroom, felt like fainting and fell. Upon admission,
the patient was made NPO, given intravenous fluids and underwent
imaging. CT scan imaging of the head and cervical spine showed
no fractures. A CT scan of the abdomen/pelvis showed no
abnormality. CT scan imaging of the chest showed a right ___
rib fracture and a left 10 rib fracture. The patient was
transferred here for further evaluation and rib pain management.
Of note, the patient was straight cath'ed in the EW for a urine
specimen which showed >100,000 e.coli. She was give a dose of
macrobid. Urine cultures were pending at the time of this note.
Ms. ___ was transferred to ___ for further care. She was
initially admitted to the acute care surgery (ACS) service in
the setting of fall with rib fracture. CXR at ___ was without
evidence of pneumothorax or acute cardiopulmonary process. After
ACS evaluation, Ms. ___ was transferred to the medicine
service for fall/syncope workup. She was placed on tele
monitoring which revealed no arrhythmias. Given the patients
goals of care, the decision was made to defer ECHO at this time.
She was treated with ceftriaxone for presumed UTI.
The ___ hospital course was stable. She tolerated regular
diet and was voiding without difficulty. Her vital signs
remained stable and she was afebrile. She was stable and
clinically ready for discharge.
Follow-up with primary care provider, Dr. ___ # ___,
follow-up urine culture from ___.
Ms. ___ was admitted to ___ for workup after a recent fall
resulting in a right 9th rib fracture.
#DNR/DNI
# Emergency contact: HCP/granddaughter ___
___
___ Issues:
====================
[] Ms. ___ will require PCP follow up for her right 9th rib
fracture and recent fall.
[] Patient maintained on home warfarin regimen. Her INR was
therapeutic. Please check ___, PRN thereafter as usually
directed.
[] Patient discharged on Cefpodxime every 12 hours for treatment
of urinary tract infection. She already received antibiotics on
___, she needs 2 doses of antibiotics on ___.
=====
Greater than 30 minutes was spent on discharge planning and
coordination.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Warfarin 2.5 mg PO DAILY16
2. ASA 81 mg daily
3. citalopram 15 mg daily
4. gabapentin 100 mg bid
5. melatonin 3 mg Qhs PRN
6. senna 17.2 mg daily
7. mirtazapine 7.5 mg daily
8. MOM ___
9. ___ PRN
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Doses
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*2 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY HLD
5. Atorvastatin 40 mg PO QPM
6. Bisacodyl 10 mg PR QHS:PRN constipation
7. Docusate Sodium 200 mg PO QHS
8. Loratadine 10 mg PO DAILY
9. melatonin 3 mg oral QHS
10. Milk of Magnesia 30 mL PO PRN constipation
11. Mirtazapine 7.5 mg PO QHS
12. Senna 17.2 mg PO QHS
13. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall resulting in rib fracture
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were transferred to ___ for evaluation of a recent fall.
You were initially seen at ___, underwent a CT
scan of the head, chest, abdomen and pelvis, and found to have a
fractured rib after an unwitnessed fall from standing. You were
subsequently sent to ___ for further management of your rib
fracture and workup of the reason you fell.
A chest x-ray at ___ did not show any damage to your lung from
the rib fracture. Your heart rate and rhythm were monitored
throughout your hospital stay to assess whether or not an
abnormal heart rhythm may have caused you to fall. We did not
witness any abnormal heart rhythms while you were being
monitored at ___. We did not find a discrete reason for why
you fell- it is possible that your blood pressure fell when you
stood up from bed and made you dizzy enough to fall. It is also
possible that you were dehydrated and developed low blood
pressure upon standing. It is also possible that you had a
urinary tract infection that contributed to you feeling dizzy
upon standing. At time of discharge, you were not experiencing
episodes of dizziness, had no witnessed abnormal heart rhythms,
and were felt to be safe for discharge.
You were continued on antibiotic treatment for a urinary tract
infection, and are being discharged with 2 doses of antibiotics
to take to complete your antibiotic course.
You are being discharged with instructions to follow up with
your primary care doctor regarding your recent fall and rib
fracture.
It was a pleasure taking care of you!
Your ___ Team
Followup Instructions:
___
|
10420821-DS-29 | 10,420,821 | 23,446,234 | DS | 29 | 2179-10-31 00:00:00 | 2179-10-31 11:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bacitracin / Codeine / Ciprofloxacin / Flagyl
Attending: ___.
Chief Complaint:
Slurred speech and gait abnormality
UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ year-old woman with h/o CAD s/p MI x3 and stent
placement, PVD, right internal carotid aneurysm, presenting with
slurred speech and gait abnormality.
Pt is a poor historian, and most of the history is from OMR.
The patient was sent to the ED on ___ after an unwitnessed
fall with significant bruising on her right back. She had
unchanged CT head and no fracture on C spine imaging. She was
discharged back
to ___ where she had no dinner and had persistent very
poor oral intake including fluids. She has had previous problems
with dehydration due to poor fluid intake. This morning on
___, she was noted by her son to have slurred speech on
the
phone at around 10:00 and his wife called to confirm and agreed
her speech was slurred. Her son then called the patient's
assisted living who agreed that her speech was slurred and that
she had a right facial droop, a shuffling gait and was dragging
her right leg. She then presented to the ___ ED for
assessment.
In the ED, initial vital signs were 98.3 70 100/50 20 100%.
Patient had CT head which showed no acute intracranial
abnormality, right parieto-occipital encephalomalacia was
unchanged from prior study. UA showed 25 WBC and many bacteria.
Patient was given ceftriaxone 1g IV and may have received fluids
(unclear amount). Her neurolgic deficits improved. Neuro was
consulted and at the time of their assessment, her BP was 160s
and she had no slurred speech and was asymptomatic. They felt
that her initial hypotension and UTI contributed to recrudesence
of her prior extensive vascular infarcts. They recommended
admission to medicine for her to treatment of UTI with stroke
service following.
On the floor the pt was 98.9 196/60 80 18 99%RA. The pt stated
she was feeling "pretty lousy" because she felt her room was
"pretty shabby" and she had a suprapubic pain from the foley,
which she wanted taken out. She was not sure if she had any
weakness, and was not sure the duration of her prior symptoms
but said "maybe a week, maybe less." She was unable to recall if
she had dysuria or increased frequency.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus
or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies numbness, parasthesiae. No bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
1. Coronary artery disease - The patient is status post MI x3 in
___ and ___ with stent placement.
2. Sick sinus syndrome status post pacemaker placement - ___
3. Type 2 diabetes mellitus
4. Depression
5. Vagus nerve palsy - ___
6. History of tobacco abuse - The patient smoked for over ___
years but quit in ___.
7. Recurrent urinary tract infections
8. Chronic kidney disease
9. Iron deficiency anemia
10. Peripheral vascular disease
11. Right internal carotid artery aneurysm
12. Hypothyroidism
13. Osteoarthritis
14. Spinal stenosis status post laminectomy in ___ and fusion
of the lumbar spine in approximately ___
15. Squamous cell carcinoma
16. Falls - The patient had a serious fall on ___ down
the stairs in her home resulting in a broken coccyx. She has had
intermittent low back pain since that time. She fell again in
___ resulting in a broken left shoulder. Her most recent
fall in ___ did not result in injury.
17. Strep viridans endocarditis- ___
18. Diverticulosis on colonoscopy
19. Vascular dementia
20. GI AVM s/p cauterization
.
PAST SURGICAL HISTORY:
1. Status post pacemaker placement for sick sinus syndrome
-___
2. Lower extremity bypass - ___
3. Status post removal squamous cell carcinoma
4. Status post cholecystectomy - ___
5. Status post appendectomy - Age ___
6. Status post hysterectomy - ___
7. Status post left cataract removal - ___
Social History:
___
Family History:
The patient's mother suffered from diabetes. Her father had
cancer of the stomach and lungs. She reports that a sibling had
colon cancer. She is unclear regarding further past family
medical history.
Physical Exam:
ADMISSION EXAM:
Vitals 98.9 196/60 80 18 99%RA
General- Alert, oriented to self, not to year or location
HEENT- Sclera anicteric, slight R NLF flattening
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- ___ systolic murmur, heard best at the RUSB, no r/g
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- foley in place
Ext- warm, well perfused, no edema
Neuro- speech fluent, mild R NLF otherwise CN exam nonfocal,
strength symmetric in all extremities, pt refused to participate
in the rest of exam
DISCHARGE EXAM:
VS - 98.5F, BP 193/51, HR 82, RR 16, 98% RA
General: NAD, lying in bed, A&O to self only
HEENT: MMM, EOMI, OP clear
Neck: Supple, no masses or JVD
CV: RRR, normal S1/S2, ___ systolic murmur heard best at RUSB,
no rubs or gallops
Lungs: CTAB, no wheeze, rales or rhonchi
Abdomen: Soft, NT/ ND, no guarding, no rebound tenderness, no
organomegaly, NABS
Ext: Warm, well perfused, pulses 2+, no c/c/e
Neuro: Speech fluent, CN ___ grossly intact, gait not examined
(pt refused)
Pertinent Results:
ADMISSION LABS:
___ 01:45PM BLOOD WBC-9.1 RBC-4.05* Hgb-10.7* Hct-33.3*
MCV-82 MCH-26.4* MCHC-32.1 RDW-16.4* Plt ___
___ 01:45PM BLOOD Glucose-169* UreaN-36* Creat-1.7* Na-141
K-4.7 Cl-105 HCO3-25 AnGap-16
___ 01:45PM BLOOD Calcium-9.2 Phos-4.3 Mg-2.3
PERTINENT LABS:
___ 02:39PM BLOOD Lactate-1.7
DISCHARGE LABS:
MICROBIOLOGY:
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
___ 2:55 pm URINE Site: NOT SPECIFIED
HEME S# ___ UCU ADDED ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
DOXYCYCLINE REQUESTED BY ___ ON ___ @
12:41PM.
RESISTANT TO DOXYCYCLINE.
DOXYCYCLINE sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 10:03 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
IMAGING:
#CT HEAD W/O CONTRAST (___)
IMPRESSION:
1. No acute intracranial abnormality.
2. A rounded density in the right suprasellar region
corresponds to a
previously known right internal carotid supraclinoid aneurysm
#CAROTID DOPPLER (___)
IMPRESSION:
Significantly heterogeneous plaque at the origin of bilateral
ICAs, with
estimated percentage of narrowing between 60 and 69% bilaterally
#CT ABD & PELVIS W/O CONTRAST (___)
IMPRESSION: PRELIMINARY REPORT --> INPATIENT TEAM WILL FOLLOW
FINAL READ
1. No acute intra-abdominal or pelvic process.
2. Air within the nondependent portion of the bladder should be
correlated to recent catheterization or instrumentation.
3. Atrophic left kidney, similar in appearance compared to CT
from ___.
Brief Hospital Course:
This is an ___ year-old woman with h/o CAD s/p MI x3 and stent
placement, PVD, right internal carotid aneurysm, presenting with
slurred speech and gait abnormality. Pt was also found to have
a UTI on admission.
Pt is a poor historian and most of the history is from OMR.
ACTIVE PROBLEMS:
#R sided weakness/slurred speech: Pt presented with new slurred
speech and R sided weakness in the setting of SBP 100. HCT was
unchanged from prior and symptoms resolved with increased BP to
160s. CT head showed no acute intracranial process and no mass
effect. Neuro evaluated and felt that these symptoms were not
secondary to a new stroke but rather recrudescence of old
infarcts in the setting of UTI/hypotension. Had carotid doppler
on ___ showing heterogeneous plaque at the origin of the
ICAs bilaterally with 60-69% stenosis. No further workup
indicated at this time. Seen by ___ who evaluated the patient and
recommends rehab.
# UTI: Pt unsure if she has urinary symptoms other than
discomfort from foley. UCx from admission on ___ grew
enterococcus 10k-100k, found to be pan-sensitive. Repeat UCx
sent for this admission and pending. Pt given CTX in the ED
however this will unlikely have activity against enterococcus.
Appropriate management would be ampicillin however pt with pcn
allergy (unclear what the reaction is), and macrobid
contraindicated given pt's decreased crcl. Started on
doxycycline PO on ___. She received 3 days of doxycycline as
an inpatient and was sent home with an additional 4 days of
doxycycline. Urine culture sent on ___ also grew out Proteus
which was pan sensitive. She was sent to her ECF with a 7 day
course of cefpodoxime PO
#Nausea/Diarrhea: Began on ___. Treated nausea with IV
zofran prn providing moderate relief. Pt unable to further
characterize symptoms beyond answering yes/no/I don't know. With
recent hospitalization and abx exposure, concerned for C.
difficile infection and sent stool assay. Other considerations
include atypical chest pain or medication side effect. Had ECG
to evaluate if nausea part of atypical chest pain, and found to
be unchanged from previous ECG. Also sent lactate and had CT
abdomen w/PO contrast. Lactate was 1.7. CT abdomen was still
pending final read at discharge. Inpatient team will follow up
on final read. Nausea and diarrhea had resolved prior to
discharge.
# Hypotension: Unclear etiology. Resolved with IVF. Pt with
prior note mentioning orthostatic hypotension. Pt not a good
historian so difficult to assess if she had decreased PO intake,
though per ___ she did not eat the night prior to
admission. Also possible secondary to UTI. Currently
hypertensive.
CHRONIC PROBLEMS:
# HTN: Came in initially hypotensive which resolved with IVF.
Currently hypertensive and she remained stable on home dose of
carvedilol. Had one or two episodes where SBP was 200s-210s. Pt
reported to be asymptomatic during these episodes and was given
one time dose of labetalol which brought her SBP down to
140s-150s.
# Vascular Dementia: Confirmed pt to be at baseline per
daughter. Pt remained stable on home dose of aricept.
# Depression: Stable, continued on home mirtazapine.
# Hypothyroidism: Stable, continued on home levothyroxine
# Hypercholesterolemia: Stable, continued on home statin
# Iron deficiency anemia: Per PCP note, the patient has a
history of iron deficiency anemia. This has been investigated
with EGD and
colonoscopy in the past. Angioectasias were noted and a repeat
EGD with small bowel evaluation was recommended. This was
deferred by the patient and her son. Currently stable.
# Chronic kidney disease: Long standing, stable.
# Osteopenia: Bone density testing in ___ was significant for
osteopenia. Continued home vitamin D.
TRANSITIONAL ISSUES:
___ CT abdomen and pelvis w/ PO contrast - FINAL READ
PENDING, preliminary read: no evidence of colitits or wall
thickening.
___ unsafe for Home DC. Pt requires assist for all mobility
including adl's such as
toileting. She is a high fall risk and requires assistance with
all transfers.
#TSH as outpatient found to be slightly elevated (4.3), possible
work up as outpatient???
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Donepezil 10 mg PO HS
4. Ferrous GLUCONATE 324 mg PO DAILY
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Mirtazapine 30 mg PO HS
7. Multivitamins 1 TAB PO DAILY
8. Oyst-Cal-500 *NF* (calcium carbonate) 500 mg calcium (1,250
mg) Oral TID
9. Pantoprazole 40 mg PO Q12H
10. Pravastatin 80 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Acetaminophen 325-650 mg PO Q8H:PRN pain
13. HYDROmorphone (Dilaudid) 3 mg PO QAM
14. HYDROmorphone (Dilaudid) 2 mg PO Q4PM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Donepezil 10 mg PO HS
3. Ferrous GLUCONATE 324 mg PO DAILY
4. Mirtazapine 30 mg PO HS
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Pravastatin 80 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Acetaminophen 325-650 mg PO Q8H:PRN pain
11. Oyst-Cal-500 *NF* (calcium carbonate) 500 mg calcium (1,250
mg) Oral TID
12. Cefpodoxime Proxetil 100 mg PO Q12H
take for 5 days
13. Carvedilol 25 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Slurred speech and right sided weakness
Urinary tract infection
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms ___,
It was a pleasure taking care of you during your hospital stay.
You were admitted for slurred speech and weakness on your right
side. On arrival to the hospital, your blood pressure was lower
than normal. You were given fluids and your symptoms (slurred
speech and weakness) resolved.
You were also found to have a urinary tract infection with 2
different types of bacteria. You are being treated with
doxycycline and cefpedoxime.
While you were in the hospital, you missed your appointment with
the Cardiology Device Clinic which monitors your pacemaker. We
have rescheduled that appointment for you. The appointment
information can be found under Recommended Follow-Up.
You were seen by a physical therapist in the hospital who
determined that you were unsafe to be discharged home and
recommended that you be sent to a rehabilitation facility.
You also reported issues with nausea and loose stools while in
the hospital. Your in hospital care team did an
electrocardiogram, blood tests and CT scan of your abdomen to
look for a possible cause. All of these tests were normal. At
this time we feel that you are medically safe for discharge to
rehab.
On further review of your records, you were noted to have a
slightly high TSH from blood work on ___. We recommend that
this be followed up by your primary care physician.
Follow up appointments have been made for you. Please take your
medications as instructed.
Followup Instructions:
___
|
10421528-DS-3 | 10,421,528 | 22,828,842 | DS | 3 | 2141-04-07 00:00:00 | 2141-04-07 17:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Corticosteroids (Glucocorticoids)
Attending: ___.
Chief Complaint:
Hypotension, cough, and fatigue
Major Surgical or Invasive Procedure:
RIJ placement and removal
History of Present Illness:
History of Present Illness:
Mr. ___ is a ___ year old gentleman with HIV on HAART,
previous PCP pneumonia, and COPD who was brought to ___ from
his PCP's office after his BP was found to be 50/20's on ___,
___. He went to his PCP with complaints of worsening
cough, SOB, decreased appetite, and dizziness over the past
week.
Upon arrival to the ED, Mr. ___ was fluid ___ with
5L IV normal saline and was started on norepinephrine pressors.
A right IJ and 2 peripheral IVs were placed. CT scan of chest
and abdomen with and without contrast was notable for large
consolidation of left lower lung concerning for pneumonia. Labs
were noted to show WBC of 13.9 (78.2% neutrophils), H/H
11.9/36.4, platelet 244. Chemistry was notable for glucose 101,
BUN 41, Creatinine 4.7. Toxicology screen was positive for
benzodiazepines (takes diazepam). Urine screen was also positive
for opiates (takes oxycodone). Lactate was 2.4. Blood cultures
were obtained in the ED. No intraabdominal process as cause of
patient's symptoms were found. In the ED on ___ he received
vancomycin 1000 mg IV x 1. Piperacillin-tazobactam 4.5 grams IV
x 1. Azithromycin 500 mg IV once. Also given zofran 4 mg IV. A
portable CXR and portable abdomen was obtained. Also started on
norepinephrine 0.03-0.25 mcg/kg/min IV drip titrated to map >65.
He was thereafter transferred to ___ for further care where he
got 2L of normal saline and pressors were continued. Through
this time Mr. ___ creatinine remained at 4.7. He reported
that over the past ___ years, he had been taking ___ vicodin and
___ aspirin per day to help control back pain which started
after a car crash in the ___ but has since gotten worse.
He reports good adherence to his medications, rarely missing any
doses. After stabalized in the FICU with fluids and pressors,
Mr. ___ was transferred to ___ for further management on
___, where he remains hemodynamically stable but continues to
complain of cough, SOB, back pain, headache and generally
feeling ill. In the FICU he was found to be auto-diuresing and
on last labs prior to transfer to general medicine floor, noted
to be hypernatremic to 146.
Past Medical History:
HIV/AIDS -diagnosed ___. HAART therapy. Previously PCP
___.
Hypertension
COPD
Peripheral neuropathy
Polysubstance abuse-cocaine, heroin, alcohol use.
Anxiety/Depression
History of ___ Syndrome from steroid overuse.
Osteoporosis
Chronic Back Pain
Hypogonadism
Herpetic whitlow.
Surgeries
-cervical fusion
-facial reconstruction
Social History:
___
Family History:
Younger brother with skin cancer.
Father died of lung cancer at ___ yo.
Mother reported to be healthy.
Physical Exam:
ADMISSION PHYSICAL
==================
Vitals- 96.9, HR 95, BP 83/43, RR 22, Pulse Ox 100% on 4L nc
General: Alert, oriented, no acute distress but anxious
HEENT: Sclera anicteric, MMM, oropharynx with slight thrush,
poor dentition
Neck: supple, JVP not elevated, RIJ in place
Lungs: Minimal air movement throughout with egophony in LLL.
Patient with non-productive cough
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: very distended, not tympanic, mildly tender in LLQ and
RUQ
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL
==================
Vitals- 98.7 (Tmax 98.7), HR 90(90s-110s), BP
142/69(124-164/69-82), RR 20 (___) Pulse Ox 97% on RA
General: Alert and oriented, sitting up in bed in no acute
distress
HEENT: Sclera anicteric, moist oropharynx, cracked lips
Neck: Supple, no LAD. Well healed scar posterior midline of
neck.
Lungs: Expiratory wheezes and some course breath sounds more
pronounced in posterior dependent lung fields, good air movement
CV: Tachycardic; normal s1 and s2 with no appreciable murmurs,
rubs or gallops.
Abdomen: Diffusely tense but no focal tenderness with palpation.
Bowel sounds audible.
GU: no foley
Ext: Warm and well perfused.
Neuro: Grossly intact.
Pertinent Results:
ADMISSION LABS
==============
___ 11:05AM BLOOD WBC-13.9*# RBC-3.68* Hgb-11.9* Hct-36.4*
MCV-99* MCH-32.3*# MCHC-32.6 RDW-13.4 Plt ___
___ 11:05AM BLOOD Neuts-78.2* Lymphs-13.1* Monos-7.7
Eos-0.9 Baso-0.1
___ 11:05AM BLOOD ___ PTT-29.6 ___
___ 11:05AM BLOOD Glucose-101* UreaN-41* Creat-4.7*# Na-136
K-4.1 Cl-99 HCO3-22 AnGap-19
___ 07:00PM BLOOD ALT-22 AST-20 AlkPhos-112 TotBili-0.3
___ 11:05AM BLOOD Albumin-3.4*
___ 07:00PM BLOOD Calcium-7.0* Phos-1.7*# Mg-2.0
___ 07:00PM BLOOD TSH-0.53
___ 07:00PM BLOOD T4-5.6
___ 07:00PM BLOOD Cortsol-39.8*
___ 11:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5*
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 11:08AM BLOOD Lactate-2.4*
___ 09:29PM BLOOD Lactate-0.8
PERTINENT LABS
==============
___ 07:34AM BLOOD ___ pO2-57* pCO2-34* pH-7.29*
calTCO2-17* Base XS--8
___ 10:32AM BLOOD ___ pO2-39* pCO2-48* pH-7.20*
calTCO2-20* Base XS--10 Comment-PERIPHERAL
DISCHARGE LABS
==============
___ 06:00AM BLOOD WBC-8.7 RBC-3.58* Hgb-11.5* Hct-35.6*
MCV-100* MCH-32.2* MCHC-32.3 RDW-14.2 Plt ___
___ 06:00AM BLOOD Glucose-98 UreaN-44* Creat-4.6* Na-144
K-4.1 Cl-115* HCO3-18* AnGap-15
___ 06:00AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.0
MICRO
=====
___ URINE LEGIONELLA AG - Negative
___ MRSA SCREEN - negative
___ URINE CULTURE - no growth
___ BLOOD CULTURE X 2 - Pending
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
IMAGING
=======
___: CHEST (PORTABLE AP)
Left lower lobe consolidation due to pneumonia has grown more
radiodense.There is no cavitation as yet.Pulmonary vasculature
is more engorged, in this patient with severe
emphysemasuggesting the new opacification in the right lower
lobe could be dependentedema rather than a second focus of
pneumonia, but careful imaging followup isindicated. Pleural
effusion is small on the left if any. Heart size is normal.
___ RENAL Ultrasound: 1. No evidence of obstructive
stones or hydronephrosis. A few nonobstructingstones in the
right kidney, one of which measures 3 mm.2. Bilateral foci of
increased echogenicity in the kidneys, possiblyrepresenting
angiomyolipomas.3. Small amount of debris in the bladder, which
is otherwise normal.
___: CHEST (PORTABLE AP):
AP portable upright view of the chest. A new right IJ central
venouscatheter is seen with tip projecting over the region of
the mid SVC. Severeemphysema is re- demonstrated with dense
consolidation in the left lower lobecompatible with pneumonia.
No pneumothorax.
___: CT CHEST AND ABDOMEN/PELVIS W & W/O CON
1. Left lower lobe pneumonia.
2. Severe centrilobular emphysema.
3. No acute intra-abdominal or intrapelvic pathology.
4. Unchanged mid thoracic compression fractures.
___: KUB
Supine and upright views of the abdomen pelvis were provided.
No free air below the right hemidiaphragm. Consolidation is
present in the left lower lobe concerning for pneumonia. Bowel
gas pattern is unremarkable without signs of ileus or
obstruction. No free air below the right hemidiaphragm. Bony
structures appear grossly intact. IMPRESSION: Findings
concerning for pneumonia the left lung base. Please refer to
subsequent CT torso for further details.
___ EKG:
No ischemic changes
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of HIV on HAART
who was admitted with cough, shortness of breath and hypotension
consistent with community acquired pneumonia complicated by
septic shock and resultant acute kidney injury, now stabilized.
ACTIVE ISSUES
=============
# Septic shock secondary to community acquired pneumonia: Mr.
___ was referred to the ED on ___ by his PCP after he
was noted to be severely hypotensive. In the ED, blood pressure
was 50/20, RR>20, tachy to 100-130's with CT scan of chest
showing LLL consolidation. He was resuscitated with 5L of NS in
the ED with improvement of BP to 83/43 and subsequently
transferred to the FICU, where he required norepinephrine and
received an additional 2L NS. Lactate improved from 2.4 to 0.8
after IVF. He was given vancomycin, piperacillin-tazobactam, and
azithromycin (day 1: evening of ___ to cover broadly for
pneumonia. He was also given his home inhalers and
albuterol/ipratropium nebs for his shortness of breath. A
cortisol level was checked and was appropriately elevated at
39.8 ug/dL, ruling out adrenal insufficiency. Urine legionella
and MRSA swab were both negative. Respiratory sputum culture
grew yeast and multiple organisms consistent with oropharyngeal
flora. When hemodynamically stable, patient was transferred to
the floor and transitioned to ceftriaxone/azithromycin to cover
for community acquired pneumonia. His clinical status improved
and he remained off supplemental oxygen for 2 days prior to
discharge. He completed a 5-day course of Z-pack and was
discharged on 3 additional days of cefpodoxime (last dose ___
for a total 8-day course.
# Acute kidney injury: On admission Mr. ___ was found to
have an elevated creatinine of 4.7 coupled with BUN of 37, FeNa
of 6.6%, and muddy brown casts in urine, likely representing
ischemic ATN in the setting of renal hypoperfusion ___ septic
shock. Nephrotoxic ATN or interstitial nephritis at baseline may
also be contributory given sterile pyuria and that patient has
been taking about 1000mg NSAIDs daily for ___ years at home,
however baseline creatinine of 1.38 indicated by previous
records argued against this as a major acute etiology. Renal
ultrasound with no evidence of obstructive stones or
hydronephrosis rendered postrenal ___ unlikely. Ultrasound
report did reveal possible angiomyolipomas. Renal was consulted
during this admission. The patient underwent post-ATN recovery
diuresis but was generally able to maintain adequate PO intake.
During his stay, he was started on bicarb 650 BID to address
likely metabolic acidosis given resolution of prior hypercarbia
on VBG. Creatinine remained elevated at 4.8 from ___ and
was 4.6 on discharge. He will have followup with Dr. ___
on ___. He will have ___ services for every other day
electrolytes for further monitoring.
# HIV: Diagnosed in ___, Mr. ___ is on his third HAART
regimen consisting on admission of truvada, ritonavir and
darunivir. His CD4 counts have been in the 500's and copy
numbers undetectable. Given his impaired renal function,
pharmacy was consulted on ___ who recommended that Truvada can
be dosed renally q96h. First dose of Truvada q96h was
administered on evening of ___ ritonavir and darunavir
were continued. To test for hypersensitivity to Abacavir,
HLA-B*5701 screening was ordered and is pending at present. He
was discharged to continue ritonavir and darunavir and to take
his next dose of Truvada on ___. His PCP ___ receive every
other day creatinine checks and titrate his dose as needed.
# Hypernatremia; hyperchloremia: Hypernatremia currently
resolved, down to 142 from 146. Chloride remained elevated at
113, down from 116 earlier. These electrolyte disturbances
likely represent poor PO fluid intake or impaired renal tubular
excretion. Electrolytes were monitored and continued to improve
on discharge.
CHRONIC ISSUES
===============
# Abdominal distension: Mr. ___ notes that this distention
tends to wax and wane, and worsens after meals or constipation.
Senna/colace/Miralax was administered and improvement was noted
after bowel movement.
# COPD: Previous smoker for ___ years, ___ packs per day,
complicated in setting of pneumonia. He was initially placed on
nasal canula but was satting 96% on RA after transfer to the
floor. CXR showed some engorged pulmonary vasculature suggesting
volume overload due to fluid resusitation. Respiratory status
was monitored and remained stable throughout his stay with
continued home albuterol and ipratropium.
# Anxiety/depression: Mr. ___ reports that his mood has been
more labile over the past few weeks. He had an appointment
scheduled for ___ with his psychiatrist which he missed
due to his hospitalization. His home duloxetine and Valium
regimen was continued through his hospitalization, which he
notes has brought him much relief.
# Hypertension: His home lisinopril was held in the setting of
acute kidney injury. He was started on 5 mg amlodipine for
hypertension and discharged on this medication.
# Substance abuse: Given past use of tobacco, marijuana,
alcohol, cocaine, heroin, Mr. ___ was monitored for any
signs of withdrawal with no evidence of withdrawal during
hospitalization.
TRANSITIONAL ISSUES
====================
# Patient was discharged with 3 additional days of cefepodoxime
for community-acquired pneumonia (received 5 days of
azithro/CTX) in-house.
# The patient will have a BNP checked every other day by ___ and
faxed to his PCP ___ ___. His next BNP should be ___
___.
# Due to his worsened renal function, his Truvada will be
renally dosed every 96 hours. His next dose will be ___.
# Lisinopril was held in the setting ___ and replaced with
amlodipine 5 mg.
# He has a pending HLAB5701 test (found under Blood Bank in
OMR).
# Patient started on sodium bicarb 650 mg BID.
# CODE: full
# CONTACT: Friend & HCP ___ (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN pain
2. Diazepam 10 mg PO TID:PRN anxiety
3. Ferrous Sulfate 325 mg PO DAILY
4. Aspirin 1000 mg PO Q6H:PRN pain
5. Duloxetine 60 mg PO DAILY
6. Acyclovir 400 mg PO TID X 5 DAYS FOR RECURRENT HSV INFECTION
7. Tizanidine 4 mg PO BID:PRN muscle spasms
8. Guaifenesin ER 1200 mg PO Q12H
9. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
10. Darunavir 600 mg PO BID
11. RiTONAvir 100 mg PO BID
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs Q4-6H:PRN SOB, Wheezing
13. Albuterol 0.083% Neb Soln 1 NEB IH Q6-8H PRN bronchospasm
14. LOPERamide 2 mg PO QID:PRN diarrhea
15. Lisinopril 20 mg PO DAILY
16. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
17. Tiotropium Bromide 1 CAP IH DAILY
18. Testosterone Cypionate 200 mg/ml inject 1 ml IM Q2 WEEKS
19. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral 2 tablets daily
20. Viagra (sildenafil) 50 mg oral ___ hours prior to sexual
activity prn: ED
21. Alendronate Sodium 70 mg PO QWEEKLY
22. Baclofen 10 mg PO Q8H:PRN muscle spasms
23. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6-8H PRN bronchospasm
2. Baclofen 10 mg PO Q8H:PRN muscle spasms
3. Darunavir 600 mg PO BID
4. Diazepam 10 mg PO TID:PRN anxiety
5. Duloxetine 60 mg PO DAILY
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO Q96H
Take this medication every 96 hours. Your next dose will be
___ unless instructed otherwise.
7. Ferrous Sulfate 325 mg PO DAILY
8. Guaifenesin ER 1200 mg PO Q12H
9. RiTONAvir 100 mg PO BID
10. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
11. Tizanidine 4 mg PO BID:PRN muscle spasms
12. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Lidocaine 5% Patch ___ PTCH TD QAM apply to painful areas
RX *lidocaine 5 % (700 mg/patch) please apply ___ on your back
once daily in the morning Disp #*10 Patch Refills:*0
14. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral 2 tablets daily
16. Fluticasone Propionate 110mcg 2 PUFF IH BID
17. Alendronate Sodium 70 mg PO QWEEKLY
18. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN
pain
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs Q4-6H:PRN SOB, Wheezing
20. Testosterone Cypionate 200 mg/ml inject 1 ml IM Q2 WEEKS
21. Tiotropium Bromide 1 CAP IH DAILY
22. Viagra (sildenafil) 50 mg ORAL ___ HOURS PRIOR TO SEXUAL
ACTIVITY PRN: ED
23. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
RX *nystatin 100,000 unit/mL 5 ml by mouth four times a day
Refills:*0
24. Cefpodoxime Proxetil 200 mg PO Q24H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
25. Acetaminophen 325 mg PO Q8H:PRN pain
Do not exceed 3 tablets in one day if you are taking your
Vicodin.
26. Acyclovir 400 mg PO TID X 5 DAYS FOR RECURRENT HSV INFECTION
27. Outpatient Lab Work
Patient will need basic metabolic panel to check bicarb levels
and creatinine every other day starting on ___. These
results need to be faxed to Dr. ___ at ___.
ICD-9 code ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
# Septic shock ___ community-acquired pneumonia
# Acute kidney injury
SECONDARY DIAGNOSIS
====================
# HIV
# HTN
# COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care at ___.
You were referred to the Emergency Department by your Primary
Care Physician who was concerned about your low blood pressure
during your visit on ___ for cough, headache and shortness of
breath. You received a chest x-ray, and you were found to have
pneumonia (an infection of the lung). Due to the severity and
scope of this infection, your blood pressure was low (a
condition called 'septic shock') and your kidneys were injured
since they did not receive adequate blood supply.
You received fluids and other medications which stabilized your
blood pressure, and antibiotics to treat the pneumonia. You also
received nebulizer therapy, cough syrup, and pain medication
which brought relief to your symptoms. You will be discharged on
oral antibiotics (cefpodoxime last dose ___ to complete your
course.
Your Medicine Team worked closely with the Renal Service -
experts in kidney function, to coordinate your care and optimize
your treatment. We have started you on a new medication (sodium
bicarbonate), which you should take twice a day unless otherwise
instructed by your primary care doctor.
It is also important that you avoid medicines and substances
that may be toxic to the kidneys, including NSAIDs such as
aspirin, ibuprofen (Advil), naproxen (Aleve). We also stopped
one of your blood pressure meds (lisinopril) and replaced it
with another (amlodipine). You can continue taking Vicodin for
pain but if you are taking the Vicodin, do not take more than
one tablet of additional Tylenol every 8 hours.
We have scheduled you for follow-up appointments listed below.
The dates, addresses, and phone numbers are listed below.
We wish you all the best!
Your ___ team
Followup Instructions:
___
|
10421678-DS-13 | 10,421,678 | 27,492,977 | DS | 13 | 2158-08-02 00:00:00 | 2158-08-02 13:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
penicillin / oxacillin / diclofenac
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr. ___ is an ___ year-old male s/p mechanical fall. He
reports that he lost his footing and fell onto his back. He
denies any loss of consciousness or pre-syncopal event. He was
not able to get up by himself and required the assistance of his
fmaily members. He reported pain on the right side of his back
and side and presented to ___ where he received a CT
torso which showed a right L1, L2, L3 TP fractures and right
nondisplaced 11 and 12 rib fractures with a small pleural
effusion. He was also noted to have a hematoma on his right
flank
that was stable in size. He now continues to complain of pain in
his left side but no other significant symptoms.
Past Medical History:
Past Medical History: CHF, pacemaker, HLD, HTN, Stage III CKD,
history of stroke, DVTs s/p IVC filter, chronic anemia, back
pain
Past Surgical History: IVC filter, TURP, knee replacement b/l,
MVR - porcine valve
Allergies: NKDA
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Admission Physical Exam:
Vitals: 99.2 87 157/78 18 99% RA
GEN: A&O3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Physical Exam:
VSS
GEN: A&O3, NAD, seated comfortably in chair
HEENT: anicteric, MMM
CV: RRR, No M/R/G
PULM: Clear to auscultation b/l, No W/R/C. palm sized hematoma
on right flank mid back next to spine, unchanged in size with
old contusion overlying
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 05:10PM BLOOD WBC-5.5 RBC-2.86* Hgb-7.2* Hct-24.2*
MCV-85 MCH-25.2* MCHC-29.8* RDW-18.9* RDWSD-58.2* Plt ___
___ 04:54PM BLOOD WBC-7.4 RBC-3.28* Hgb-8.5* Hct-28.4*
MCV-87 MCH-25.9* MCHC-29.9* RDW-18.3* RDWSD-58.4* Plt ___
___ 11:05AM BLOOD WBC-5.7 RBC-3.01* Hgb-7.5* Hct-26.0*
MCV-86 MCH-24.9* MCHC-28.8* RDW-18.3* RDWSD-57.2* Plt ___
___ 05:10PM BLOOD Glucose-101* UreaN-33* Creat-1.6* Na-139
K-4.2 Cl-104 HCO3-26 AnGap-13
___ 05:58AM BLOOD Glucose-92 UreaN-26* Creat-1.5* Na-139
K-3.4 Cl-102 HCO3-26 AnGap-14
___ 11:05AM BLOOD Glucose-116* UreaN-32* Creat-1.5* Na-140
K-3.5 Cl-102 HCO3-21* AnGap-21*
CT CHEST W/O CONTRAST Study Date of ___ 10:21 AM
1. Fractures of the posterior right eleventh and twelfth ribs
and right
transverse processes of L1, L2 and L3. There is an overlying
8.9 cm hematoma
in the posterior soft tissues.
2. Heavy atherosclerotic disease with mild dilation of the
ascending thoracic
aorta measuring 4.3 cm, ectasia and mild aneurysmal dilation of
the abdominal
aorta described above, and dilation of the right common iliac
artery.
3. Mildly enlarged mediastinal lymph nodes are non-specific.
Brief Hospital Course:
The patient presented to the Emergency Department on ___ . Pt
was evaluated pon arrival to ED. Given findings of T11 and T12
posterior rib fractures with small pleural effusion, L1, L2, L3
transverse process fractures, R flank hematoma the neurosurgery
was consulted. The patient was deemed to have no operative
trauma and no need for brace. Please see neurosurgery note for
details. Pt was transfered to the floor in stable condition for
observation and serial hematocrits. His hematocrit remained
stable the subsequent day (26.7->28.4)
Neuro: The patient was alert and oriented throughout
hospitalization.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. There was
nursing concern on expanding flank hematoma on the ___. It was
evaluated by the team and found to be soft and stable, his
hematocrit was also unchanged at 26 (stable v ___. His blood
pressure was in the ___ sys, systolic but responded well to a
500cc NS bolus. On re-evaluation the afternoon of the ___, the
hematoma remained unchanged.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was given a Regular diet, which was well
tolerated. Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Medications:
lasix 40', metoprolol 25', donepazil 5mg', tramadol 50', celexa
10'
Discharge Medications:
1. Furosemide 45 mg PO DAILY
2. Donepezil 5 mg PO QHS
3. Citalopram 10 mg PO DAILY
4. TraMADOL (Ultram) 50 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO DAILY
6. Milk of Magnesia 30 mL PO Q6H:PRN constipation
7. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
T11 and T12 posterior rib fractures with small pleural effusion,
L1, L2, L3 transverse process fractures, R flank hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___:
You were admitted to ___ and
underwent imaging, stabalization, observation, evaluation, and
physical therapy. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
* Your injury caused T11 and T12 posterior rib fractures rib
fractures which can cause severe pain and subsequently cause you
to take shallow breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10421969-DS-23 | 10,421,969 | 23,350,379 | DS | 23 | 2178-11-21 00:00:00 | 2178-11-21 20:40:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Neomycin / Codeine / latex
Attending: ___.
Chief Complaint:
Left buttock pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with PMH of HTN, discoid
lupus, and pseudoarthritis/degenerative disc disease/scoliosis
with recent anterior/posterior fusion L5-S1 2 months ago who
presents with atraumatic left buttock pain w radiculopathy x
several month duration with worsening over the last 2 weeks.
Pt. reports prior to most recent back surgery a several year
history of significant lower back associated with bilateral leg
pain. For approx ___ year, the pt. reports sleeping in a chair,
unable to lie down. She had been ambulating in a flexed forward
posture, had difficulty with ___ extension, and had neurogenic
claudication. Immediately following her recent surgery, pt.
reports resolution of her previous symptoms. She reports that
this left buttock pain began sometime at rehab. She localizes
the pain in the left gluteal region, lateral to the SI joint,
near the sciatic notch. She describes the pain as a burning
sharp localized pain at rest, made worse with sitting or
movement. The pain does radiate to the anterior/posterior thigh
as well as the anterior and posterior lower back and lower
abdomen. She denies any numbness/tingling/weakness in the upper
or lower extremities.
Pt. had been seen several times over the last few weeks for her
pain. Initially, pt. was seen by Dr. ___ a medrol
dose pack with gabapentin for her pain. The pt. reports
intermittently taking her gabapentin ___ to a globus sensation
in her chest associated with dysphagia. Most recently, the pt.
was evaluated in the ___ ED on ___ and started on tramadol
as well as 5 days of macrobid for urinary incontinence and a UA
suggestive of a UTI (a urine cx. was not sent).
Pt. denies fevers, chills, rigors, chest pain, back pain, or
other localizing symptoms. She does endorse ongoing nausea, GI
upset, and intermittent constipation that she attributes to her
narcotic use. In this setting, the pt. endorses a recent 10 lbs
weight loss. She ambulates with a walker currently.
In the ED, initial vs were: 4 97.6 66 157/78 16 96%. Labs were
remarkable for Na 129, Hct 36 (bl low ___, UA negative. Patient
was given zofran, IVF, and 5mg morphine. CT Pelvis showed
possible loosening of hardware but Ortho felt this was
non-operative.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. Ten
point review of systems is otherwise negative.
Past Medical History:
#Benign Spinal Cord Meningioma - s/p large complicated resection
at ___ which resulted in significant scoliosis
#Scoliosis - s/p fusion with complications of pseudoarthrosis
and failure of instrumentation at the thoracolumbar junction s/p
anterior T10-L4 fusion (___)
#Degenerative Disc Disesae - ___ scoliosis with foraminal
stenosis at L5-S1 now s/p L5-S1 interbody fusion (___)
#Hx of Discoid lupus - s/p skull skin lesion resection
#Inferior myocardial wall MI based on EKG
Social History:
___
Family History:
N/C
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T 99.1, HR 72, BP 121/47, RR 18, Sat 98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, early systolic flow
murmur heard best at RUSB, otherwise no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: well healing vertical mid-line surgical scar, soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Scattered ecchymosis throughout (pt. states easy bruising
history of long duration)
Neuro: A/Ox3, sensation intact to light touch in the dermatomes
of the lower extremities, strength ___ ankle dorsi and plantar
flextion, ___ hip extension (limited by pain on left), negative
straight leg raise and negative crossed straight leg raise
DISCHARGE PHYSICAL EXAM:
========================
Vitals: T 98.4, HR 62, BP 142/72, RR 18, Sat 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: well healing vertical mid-line surgical scar, soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses
Neuro: A/Ox3, sensation intact to light touch ___ bilaterally,
strength ___ ankle dorsi/plantar flextion, ___ hip extension
(limited by pain on left), pain on direct palpation near the
sciatic notch on left buttock
Pertinent Results:
ADMISSION LABS
==============
___ 05:00PM BLOOD WBC-6.1 RBC-3.87*# Hgb-11.7*# Hct-36.0#
MCV-93 MCH-30.3 MCHC-32.6 RDW-12.6 Plt ___
___ 05:00PM BLOOD Neuts-79.2* Lymphs-12.1* Monos-6.2
Eos-0.8 Baso-1.7
___ 05:00PM BLOOD Glucose-77 UreaN-13 Creat-0.7 Na-129*
K-4.5 Cl-93* HCO3-24 AnGap-17
NOTABLE LABS
============
___ 05:45AM BLOOD WBC-5.1 RBC-3.86* Hgb-11.7* Hct-36.0
MCV-93 MCH-30.4 MCHC-32.6 RDW-12.7 Plt ___
___ 05:45AM BLOOD Glucose-87 UreaN-14 Creat-0.7 Na-132*
K-4.1 Cl-95* HCO3-25 AnGap-16
___ 05:00PM BLOOD CRP-5.3*
DISCHARGE LABS
==============
___ 05:20AM BLOOD WBC-4.3 RBC-3.75* Hgb-11.4* Hct-34.9*
MCV-93 MCH-30.6 MCHC-32.8 RDW-12.4 Plt ___
___ 05:20AM BLOOD Glucose-88 UreaN-16 Creat-0.6 Na-128*
K-4.2 Cl-93* HCO3-27 AnGap-12
___ 05:20AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.9
STUDIES
=======
MRI PELVIS (___): Prelim: No evidence of fracture
CT PELVIS (___): 1. No fracture 2. Symmetric lucency
around the bilateral S1 fixation screws. Findings are new since
prior study from ___, have increased over time, and
are consistent with hardware loosening.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT: Ms. ___ is a ___ year old female
with PMH of HTN, discoid lupus, and pseudoarthritis/degenerative
disc disease/scoliosis with recent anterior/posterior fusion
L5-S1 2 months ago who presents with atraumatic left buttock
pain without classic radiculopathy over the last several months
duration with worsening over the last 2 weeks now improved. Pt.
had no clear fracture on pelvic XRAY. An MRI was done which was
preliminarily negative for fracture. Pt. also had hyponatremia
likely ___ poor PO intake and a component of SIADH ___ her
nausea and pain. She was continued on a 5 day course of macrobid
which resolved her symptoms of urinary incontinence. She
continued to have urinary frequency and was discharged with a
short course of pyridium. Otherwise, her pain improved on
standing tylenol, naproxen, tramadol, and PRN PO morphine.
ACTIVE ISSUES:
# Buttock Plan: Pt. with several month history of atraumatic
left buttock pain. Pain was found to be localized laterally to
the SI joint in the vicinity of the sciatic notch and
reproducible on direct palpation. Pt's pain was treated with
standing naproxen, tylenol, tramadol, and PO morphine with
relief. She had a CT pelvis which was negative for acute
fracture but did reveal a symmetric lucency around the bilateral
S1 fixation screws which may be consistent with hardware
loosening. Dr. ___ Ortho ___ was consulted and
recommended further imaging with MRI to evaluate for sacral
fracture. Prelim results were negative for any acute fracture.
Otherwise, pt. reports improvement of her pain symptoms.
# Hyponatremia: Pt. with low-grade hyponatremia on admission
with Na ranging from 128-132. This was thought to be secondary
to poor PO intake and possibly from a component of SIADH from
nausea and pain. Pt. should have sodium rechecked ___ days
following discharge.
# UTI: Pt. with new urinary incontinence several days prior.
While in the ___ ED with above pain, pt. with UA revealing
>100 WBCs. No culture data sent. Pt. had urinary incontinence
resolution with 5 day course of macrobid (day 1 ___ -
___. Pt. continued to have urinary frequency at time of
discharge. She had a repeat UA which was negative, urine
culture pending. She was started on a 3 day course of pyridium
PRN for symptom management.
# Constipation: Pt. with significant constipation likely ___
narcotic induced ileus. Pt. responded well to aggressive bowel
regimen and continued on standing colasce, senna and PRN
miralax, bisacodyl, and milk of magnesia.
CHRONIC ISSUES
#Discoid Lupus: Stable. Continued on hydroxychloroquine
sulfate 200mg PO BID.
#Hypothyroidism: Stable. Continued on levothyroxine.
#Inferior myocardial wall/CAD/CVA Prophylaxis: Stable.
Continued on aspirin 81mg PO Daily.
#HTN: Stable. Continued on captopril 50mg PO TID
#GERD: Stable. Continued on omeprazole 20mg PO Daily
TRANSITIONAL ISSUES
===================
#Hip Pain and MRI Results: Pt. should continue on standing
naproxen, tylenol, tramadol, with PRN morphine PO. Pt. will be
notified of MRI results and will follow-up with Dr. ___ as an
outpatient.
#Hyponatremia: Pt. should have repeat Na checked ___ days post
discharge to ensure resolution of hyponatremia.
#Urinary Frequency: Pt. should continue pyridium as needed for 3
days through ___. If pt. continues to have dysuria, pt.
should have repeat UA and Urine Culture for evaluation.
#Question of Inferior Wall MI in Past: Pt. with ? of missed MI
in the past. She may benefit from statin if this is the case.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO DAILY
2. Captopril 50 mg PO TID
3. Hydroxychloroquine Sulfate 200 mg PO BID
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Nystatin Cream 1 Appl TP BID:PRN Rash
6. Omeprazole 20 mg PO DAILY
7. Vitamin B Complex w/C 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Bisacodyl 10 mg PO/PR DAILY
10. Docusate Sodium 100 mg PO BID:PRN Constipation
11. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
12. Aspirin 81 mg PO DAILY
13. Halobetasol Propionate 0.05 % topical Daily;PRN rash
14. Magnesium Oxide 400 mg PO DAILY:PRN leg cramps
15. Milk of Magnesia 30 mL PO Q6H:PRN Constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Calcium Carbonate 500 mg PO DAILY
4. Captopril 50 mg PO TID
5. Docusate Sodium 200 mg PO BID
6. Hydroxychloroquine Sulfate 200 mg PO BID
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Milk of Magnesia 30 mL PO Q6H:PRN Constipation
9. Omeprazole 20 mg PO DAILY
10. Acetaminophen 1000 mg PO Q8H
11. Heparin 5000 UNIT SC TID
Can be discontinued once mobility improves.
12. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) apply to left buttock daily
Disp #*1 Box Refills:*0
13. Naproxen 500 mg PO Q8H
14. Phenazopyridine 100 mg PO TID Duration: 3 Days
15. Polyethylene Glycol 17 g PO BID:PRN Constipation
16. Senna 1 TAB PO BID
17. TraZODone 25 mg PO HS:PRN Insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*4 Tablet Refills:*0
18. Nystatin Cream 1 Appl TP BID:PRN Rash
19. Vitamin D 1000 UNIT PO DAILY
20. Vitamin B Complex w/C 1 TAB PO DAILY
21. Halobetasol Propionate 0.05 % topical Daily;PRN rash
22. TraMADOL (Ultram) 50-75 mg PO Q4H
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
23. Morphine Sulfate (Oral Soln.) 5 mg PO Q6H:PRN pain
RX *morphine 10 mg/5 mL ___ mL by mouth every six (6) hours
Disp ___ Milliliter Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Left Sacroiliac Pain
SECONDARY DIAGNOSES:
- Degenerative Disc Disease with lumbar disc degeneration ___
- s/p recent anterior/posterior fusion (___)
- HTN
- Discoid lupus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure meeting you and caring for you during your
recent hospitalization at ___.
You were admitted for evaluation of significant pain in your
left backside. You had an MRI which on the preliminary read did
not show any fracture but the final results were pending at
discharge. Your pain was controlled with standing tylenol,
naproxen, tramadol as well as morphine as needed. Dr. ___
___ saw you and helped us manage your hospitalization. You
were previously diagnosed with a urinary tract infection and
completed your course of antibiotics while in the hospital. You
continued to have some urinary frequency for which we gave you a
medication to help relieve those symptoms. You were discharged
to a ___ rehab facility where you can continue to work on
your pain control and begin your rehabilitation.
All the best,
Your ___ Care Team
Followup Instructions:
___
|
10421990-DS-4 | 10,421,990 | 24,890,548 | DS | 4 | 2121-03-03 00:00:00 | 2121-03-04 06:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right sided abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ with no significant medical history who
presented with acute onset right sided abdominal pain that began
after eating dinner on ___. He describes the pain as cramping
and severe, and initially was more located in the epigastric
region but slowly migrated towards the right side and lower
abdomen. The pain persisted overnight and into the morning, and
so he decided to come to the ED for evaluation. Of note, he was
able to eat breakfast and drink well on the morning of ___.
In the ___ ED, Mr. ___ exam was notable for right sided
abdominal tenderness to deep palpation in the periumbilical and
right lower quadrants. He denied nausea/vomiting, fevers,
chills, SOB, chest pain, dysuria, or changes in bowel habits.
Past Medical History:
None
Social History:
___
Family History:
noncontributory
Physical Exam:
Physical Exam:
Vitals: 97.4 61 112/64 18 97RA
Gen: NAD, A&Ox3
HEENT: NC/AT, EOMI
CV: RRR
Pulm: easy work of breathing on RA, normal chest rise
Abd: soft, nondistended, tender to deep palpation in right
periumbilical and lower quadrant. No rebound, guarding,
nonperitoneal, no masses or hernias appreciated.
Ext: warm and well perfused
Pertinent Results:
___ 11:18AM BLOOD WBC-6.8 RBC-5.32 Hgb-16.2 Hct-45.8 MCV-86
MCH-30.5 MCHC-35.4 RDW-12.4 RDWSD-38.5 Plt ___
Brief Hospital Course:
Mr. ___ was admitted to the hospital on ___ and received a
laparoscopic appendectomy later that night. His course was
uncomplicated and he was discharged on ___.
Medications on Admission:
Medications - Prescription
BENZOYL PEROXIDE - benzoyl peroxide 6 % topical cleanser. Use as
face wash daily
CLINDAMYCIN PHOSPHATE [CLEOCIN T] - Cleocin T 1 % lotion. Apply
to face daily, each morning
TRETINOIN [RETIN-A] - Retin-A 0.05 % topical cream. Apply pea
sized amount to face each night at bedtime ___ cause dryness,
irritation
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
Use this medication as the first-line for pain
RX *acetaminophen 325 mg 2 capsule(s) by mouth three times a day
Disp #*80 Capsule Refills:*0
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
Alternate with Tylenol (acetaminophen)
RX *ibuprofen [Advil] 200 mg 2 tablet(s) by mouth three times a
day Disp #*60 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH
PAIN
You do not need to take this medication if your pain is well
controlled with tylenol
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*5 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ and
underwent laparoscopic appendectomy. You are recovering well and
are now ready for discharge. Please follow the instructions
below to continue your recovery:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
-Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
-You may climb stairs.
-You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
-Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
-You may start some light exercise when you feel comfortable.
-You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
-You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
-You may have a sore throat because of a tube that was in your
throat during surgery.
-You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
-You could have a poor appetite for a while. Food may seem
unappealing.
-All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
-Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you may have small plastic
bandages called steri-strips. Do not remove steri-strips for 2
weeks. (These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay). If
your incisions are closed with dermabond (surgical glue), this
will fall off on it's own in ___ days.
-Your incisions may be slightly red. This is normal.
-You may gently wash away dried material around your incision.
-Avoid direct sun exposure to the incision area.
-Do not use any ointments on the incision unless you were told
otherwise.
-You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
-You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
-Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
-If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
-It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
-Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
-You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
-Your pain medicine will work better if you take it before your
pain gets too severe.
-Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
-If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
-Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Warm regards,
Your ___ Surgery Team
Followup Instructions:
___
|
10422006-DS-17 | 10,422,006 | 22,646,000 | DS | 17 | 2149-08-26 00:00:00 | 2149-08-26 17:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
prednisone / Percocet / lactose / ciprofloxacin
Attending: ___.
Chief Complaint:
Abnormal Labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a PMH of Lynch syndrome s/p complete
colectomy w/ end ileostomy and urinary diversion, HTN, DM,
obesity, who presented from her nursing home with potassium
elevated to 6.9 and a sodium of 122. Patient reports she has
chronically elevated potassium, although not to this extent. Her
only current symptoms are weakness, fatigue, and lightheadedness
when she stands. She reports poor PO intake for the past ___
weeks, eating only boosts supplements at meals. She has nausea
with episodes of vomiting when taking pills, although none in
the past couple days. She reports that she isn't sure about what
her ostomy or urine output have been recently, but hasn't
noticed any changes. She endorses some recent weight loss,
denies new back or abdominal pain.
Pt denies any chest pain, SOB, palpitations, abdominal pain,
headache, new nausea/vomiting.
Of note, the patient was was initially diagnosed with rectal
cancer in her ___. Subsequent genetic testing as being positive
for Lynch syndrome. She subsequently also developed endometrial
cancer and underwent a hysterectomy with postoperative radiation
therapy and subsequent to that developed transitional cell
cancer of her right kidney and underwent a nephrectomy with
ureterectomy on that side. She has subsequently developed
complete urinary incontinence and has failed other therapies.
She was admitted on ___ for joint operation between
colorectal surgery and urology - exploratory laparotomy,
completion right colectomy, resection of her colostomy, and
ileal loop urinary diversion and was noted to have rising Cr.
from baseline 0.9-1.2 up to 1.8 with presumed ___.
In the ED, VS: 98.0 74 ___ 98% RA. Exam was notable for
mild crackles in R lower lung base, osteomy and urine diversion
bags with ongoing output and no blood, urine with concentrated
appearance, open surgical wound in lower midline, 4+ pitting
edema in lower extremities bilaterally, no CVA tenderness.
She recieved a 1L NS bolus, Sodium bicarb with D5W continuous at
150ml/hr x2L. Insulin 10 units, Lasix 20mg IV, and 1g
Ca2+gluconate.
Notable labs:
118 |89 | 49 AGap=27
-------------<133
7.4 | 9 | 2.3
1.0
7.2>----<410
EKG: no tall peak T wave
Imaging:
Ct abd/pelvis w/ contrast ___ (wet read):
1. Status post ileal loop urinary diversion with mild
hydronephrosis, which is felt to be postoperative in nature.
2. Status post total colectomy with right lower quadrant
colostomy. No evidence for ileus or bowel obstruction.
3. Additional post-laparotomy findings, including a large
midline incision site, mesenteric fat stranding, and small
volume simple ascites.
Consults:
-Colorectal surgery
-Nephrology
Recommendations:
- obtaining CT abd to r/o post-obstructive uropathy
- Consider urology consultation
- Obtain urine analysis, urine lyte and urine protein/creatinine
ratio
- Give calcium gluconate 1 g IV stat
- Start 5% dextrose in 3 amps of bicarb 1 L bolus following by
rate of 150 ml/hr
- Check Lyte q 4 hours
On arrival to the FICU, patient is hemodynamically stable,
unremarkable EKG, alert/oriented without complaint.
Past Medical History:
Lynch syndrome
transitional cell carcinoma s/p R nephrectomy
uterine cancer s/p TAH/BSO followed by radiation
rectal cancer s/p APR
Urostomy formation with ileal pouch
HTN
Diabetes
obesity
arthritis
Social History:
___
Family History:
Lynch syndrome - mother
heart disease - mother
Physical ___:
On admission:
Vitals: BP:118/54 P:83 R:20 O2:100%
GENERAL: Elderly female in bed a/ox3
HEENT: Dry MMM, oropharynx clear
NECK: supple, no LAD
LUNGS: mild crackles at bases
CV: RRR, normal S1/S2, no M/R/G
ABD: midline abdominal wound open without surrounding signs of
erythema or exudate. Colostomy in place no output, and ileostomy
EXT: Warm, +1 pitting edema
Neuro:
CN III-XII intact
Able to move all 4 limbs with purpose,
L leg numbness/reduced sensation
On discharge:
VS- 98.9 92-96/43-53 18 98%RA
I: 8 hrs: (120 po)/(300uro+450 ileostomy) 24 hours: (1660
po)/(700 urostomy + 1000 ileostomy)
Gen: sitting up comfortably in bed, NAD
HEENT: MMM, oropharynx clear
CV: heart sounds distant, RRR no m/r/g
Resp: CTA bilaterally
Abd: soft, non-tender, non-distended. Urostomy bag on Left side;
colostomy bag on right side. Stoma sites clean with no
surrounding erythema or edema. Wound vac in place
Extremities: 1+ bilateral pitting edema. Diminished strength in
left lower leg cannot lift. No sensation on anterior surface of
left. Neuro: A+Ox3, EOMI
Pertinent Results:
On admission:
___ 06:40PM BLOOD WBC-7.2 RBC-4.12 Hgb-11.0* Hct-34.7
MCV-84 MCH-26.7 MCHC-31.7* RDW-16.4* RDWSD-50.3* Plt ___
___ 06:40PM BLOOD Neuts-77* Bands-0 Lymphs-12* Monos-7
Eos-4 Baso-0 ___ Myelos-0 AbsNeut-5.54 AbsLymp-0.86*
AbsMono-0.50 AbsEos-0.29 AbsBaso-0.00*
___ 06:40PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+ Tear
Dr-1+
___ 02:00AM BLOOD ___ PTT-23.9* ___
___ 06:40PM BLOOD Glucose-133* UreaN-49* Creat-2.3* Na-118*
K-7.4* Cl-89* HCO3-9* AnGap-27*
___ 02:00AM BLOOD Albumin-2.8* Calcium-9.3 Phos-4.9* Mg-1.8
___ 02:04AM BLOOD ___ pO2-35* pCO2-43 pH-7.39
calTCO2-27 Base XS-0
___ 06:53PM BLOOD Glucose-131* Na-123* K-7.0* Cl-95*
calHCO3-14*
___ 09:49PM BLOOD Glucose-82 Lactate-2.3* Na-126* K-6.5*
Cl-93* calHCO3-19*
___ 06:53PM BLOOD Hgb-12.4 calcHCT-37
Reports:
___ EKG
Sinus rhythm. Within normal limits.
___ CT ABD & PELVIS W/O CONTRAST Study Date of ___ 10:09
___
IMPRESSION:
1. Status post ileal loop urinary diversion with mild left
hydronephrosis,
which may be postoperative in nature.
2. Status post total colectomy with right lower quadrant
colostomy. No
evidence for ileus or bowel obstruction.
3. Additional post-laparotomy findings, including a large
midline incision
site, mesenteric fat stranding, and small volume ascites.
Micro:
___ 1:20 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
Time Taken Not Noted Log-In Date/Time: ___ 3:44 am
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 32 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Discharge labs:
___ 06:35AM BLOOD WBC-3.9* RBC-2.80* Hgb-7.6* Hct-25.3*
MCV-90 MCH-27.1 MCHC-30.0* RDW-19.3* RDWSD-60.4* Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-107* UreaN-22* Creat-1.5* Na-133
K-5.4* Cl-103 HCO3-20* AnGap-15
___ 06:35AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.7
Brief Hospital Course:
Ms. ___ is a ___ year old F with Lynch syndrome with a history
of multiple cancers who is s/p total colectomy with end
ileostomy as well as urinary diversion with ileal conduit in
late ___ who presented from rehab with hyperkalemia,
hyponatremia and acute kidney injury after weeks of poor PO
intake and high ileostomy output.
# Hyponatremia: Patient initially presented with a Na+ of 122
and a hypovolemic hyponatremia. She had a urine osm of 249 and
FeNa 0.9%. The hyponatremia was thought to result from decreased
PO intake over many weeks and large output from her ileostomy.
Patient complained of pain and weakness but was not confused or
lethargic. Her sodium was corrected with IVF fluids and improved
to normal range on po diet by discharge.
# Hyperkalemia: K+ was 6.8 on admission without EKG changes. She
was initially admitted to the ICU and treated with insulin,
dextrose and lasix as well as fluid resuscitation. She had no
EKG changes and her hyperkalemia resolved quickly after
admission. She had an additional two episodes of hyperkalemia
during her admission that was thought to be secondary to
worsening ___ in context of losses and minimal intake. Again,
she improved quickly with IV fluids and Dextrose plus insulin.
On discharge her K was elevated slightly to 5.5 so sodium
bicarbonate was added and labs should be rechecked at her rehab
facility.
#ileostomy and urinary diversion: Patient initally had very
watery, large output from ileostomy ~ 2L/day. With a total
colectomy, expected 24 hour output should be less than 1.2 L.
She was started on Psyllium fiber wafers, Lomotil and loperimide
and output decreased to around 1L daily and consisted of formed
stool. She required IV fluids on multiple occasions during her
hospitalization to maintain a neutral fluid balance. She was
prescribed 500ml of PO fluids TID to help ensure adequate PO
intake. By discharge, her ileostomy output averaged
approximately 1 L output daily but in the setting of improved
input of po fluids to compensate we felt it was adequate control
of the output.
# ___: Cre 2.3 on admission, improved to 1.5 by discharge after
fluid balance was improved. This was likely pre-renal in context
of decreased PO intake and high ileostomy output. Per her
records, her baseline Cre is likely 1.2-1.4. She is s/p
nephrectomy in ___ and appears to have some underlying CKD.
Renin and Aldosterone levels were both checked for concern of
Type IV RTA, and were both elevated, an appropriate response in
the setting of hypovolemia.
#Metabolic Acidosis: Patient initially presented with a
non-anion gap acidosis, felt to be due to high ileostomy output.
It improved rapidly with bicarbonate administration and this was
stopped prior to time of transfer to the floor.
#Open abdominal wound/wound vac: The patient's central abdominal
surgical wound is currently open and is closing by secondary
intention from her procedure in late ___. The wound vac is
black on white foam. Colorectal surgery is following her for
this, and replaced the wound vac on ___ prior to her discharge.
She will follow-up with the colorectal team as an outpatient.
#Decreased appetite: Pt presented with very little PO intake
over many weeks. Still complains of decreased appetite and
difficulty eating psyllium wafers. She was started on 30mg
mirtazapine to boost her appetite. Pt reports interval
improvement of appetite and improved her po intake of food
significantly during her hospitalization here. She experienced
intermittent nausea and vomiting during her hospitalization for
which she was given zofran.
#Pyuria-asympt: Patient had a UA on admission with WBC 182, with
21RBC, and many bacteria and a urine culture grew E coli
>100,000 and another GNR>100,000. She was assymptomatic,
afebrile, with no white count and no CVA or suprapubic
tenderness. GNRs to be expected with ileal conduit, will not
treat in the absence of clinical signs of infection. Will
maintain high index of suspicion for infection, however, UAs in
this patient should be expected to have bacteria due to her
ileal conduit.
Transitional Issues:
========================================================
1. Electrolytes, especially K should be checked on ___ at
rehab to ensure that they have stabilized and that the patient
is taking in adequate po's. These labs should be read by the
physician at rehab. If her Cr increases, she may require more
aggressive oral intake repletion. HCO3 dose can be titrated as
needed. Additional lab monitoring interval after result on
___ to be determined at that time.
2. In's and Out's should be carefully monitored at rehab to
ensure that her po intake is sufficient to offset her ostomy
losses.
3. She reports that she has not been seen by Dr. ___
urologist, since her urostomy with ileal diversion was created.
An appointment with him should be made when her acute issues
have resolved.
4. She is currently being discharged on high dose loperamide and
lomotil which were recommended by the colorectal team to
decrease ileostomy output. Please monitor her ostomy output
carefully to ensure that her output does not fall significantly.
Please have a low threshold to lower or stop loperamide/lomotil
if she has consistent output <700 cc daily in order to prevent
obstruction.
5. Pt with BP's in 90's/40's. Holding home metoprolol but she
was asymptomatic at those blood pressures. In the future low
dose midodrine can be considered if required.
6. For DVT prophylaxis, we are holding heparin due to its
ability to exacerbate hyperkalemia/type IV RTA. She is on
renally dosed Lovenox.
#Code: Ok compressions/shock, do not intubate
#Communication: HCP ___ (___)
#___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO DAILY
2. Psyllium Wafer 2 WAF PO BID
3. Citalopram 40 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Enoxaparin Sodium 40 mg SC DAILY prophylaxis
Start: ___, First Dose: First Routine Administration Time
6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY
7. Ropinirole 0.75 mg PO QPM
8. Nortriptyline 10 mg PO QHS
9. Zolpidem Tartrate 5 mg PO QHS
Discharge Medications:
1. Outpatient Lab Work
Diagnosis: Hyponatremia 276.1
Check Chem 10, CBC on ___
Send results to Provider at rehab
___ send results to ___
(___)
2. Enoxaparin Sodium 30 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
3. Aspirin 81 mg PO DAILY
4. Gabapentin 300 mg PO DAILY
5. Psyllium Wafer 2 WAF PO BID
6. Ropinirole 0.75 mg PO QPM
7. Zolpidem Tartrate 5 mg PO QHS
8. Diphenoxylate-Atropine 1 TAB PO Q6H
9. LOPERamide 6 mg PO QID
10. Miconazole Powder 2% 1 Appl TP BID rash
11. Mirtazapine 30 mg PO QHS
12. Sodium Bicarbonate 1300 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- High output ileostomy
- Acute renal failure c/b hyponatremia and hyperkalemia
- Depression with anorexia
Secondary:
- Lynch Syndrome c/b rectal cancer
- CKD stage III
- Diabetes mellitus type II; diet controlled
- Perioperative left femormal nerve injury
- Restless leg syndrome
- Completion colectomy, end ileostomy, ileal loop urostomy
(___)
- Transitional cell carcinoma s/p right nephrectomy (___)
- Abdominal perineal resection (___) resite L->R colostomy
(___)
- Uterine cancer s/p TAH/BSO and XRT c/b bladder incontinence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital from your rehab center because you were found to
have some abnormalities in your electrolytes, specifically a low
sodium level and a high potassium level. You also had some
kidney injury. It is likely that this was all due to you being
very dehydrated, as you were losing lots of water from your
ileostomy bag and you had not been taking in much food or water
in the weeks before your hospitalization.
In the hospital you were initally in the ICU and then were
transferred to the regular medical floor. You were given some IV
fluids to correct your dehydration. You were also put on some
medications (Loperimide and Lomotil) to decrease the output from
your ileostomy. These worked well and the output from your
ileostomy decreased to the normal amount for patients with this
type of surgery.
You had poor appetite in the weeks prior to your
hospitalization. We worked with you on increasing your intake of
foods and fluids and also started a medication called
mirtazapine to help increase your appetite. This medication also
works to improve mood. You were taken off your other mood
medications (citalopram, nortriptyline).
When you were discharged from the hospital your sodium and
potassium levels were within the normal range. We encourage you
to take in lots of fluids every day to avoid becoming dehydrated
again. This is especially important since you will lose some
water from your ileostomy. These electrolyte levels will be
checked every few days at rehab to make sure they remain normal.
You will follow-up with the Colorectal Surgery team, the Kidney
Team and your primary care physician.
Again, it was a pleasure meeting you and taking care of you.
Your team at ___
Followup Instructions:
___
|
10422409-DS-13 | 10,422,409 | 24,276,716 | DS | 13 | 2187-07-28 00:00:00 | 2187-07-28 13:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
elevated CSF protein
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ M w/ no significant PMH
He states that he had sudden onset headache on ___ centered
around his occiput which reached maximum intensity in a few
seconds. Headache started right after an orgasm. He states it
felt like he got hit in the head with a baseball bat. No
neurologic symptoms (weakness, numbness, tingling, double
vision,
dysarhtira) during this. He states he laid down on couch, put
ice
pack on head. The headache lasted 20 minutes and was ___. He
went to sleep and gone when he woke. This was a mostly throbbing
sensation.
He states prior he had been in his USOH. He notes he went
mountain biking on ___ for 5 hours. HA doesn't seem to
worsen with sitting or standing. On ___ night had been
drinking with friends, more alcohol intake than he normally
does.
After he woke up on ___, later in the evening his headache
returned but was not as intense. He has been having intermittent
headache in the same area starting ___ night. Less intense
ranges from ___. It is mostly pressure, he has it during
interview and states it is ___.
For the last few years, in the R ear states loud noises makes
sound become distorted. Sometimes can hear heartbeat in his ears
sometimes, made it hard for him to hear, sometimes happening
since ___ or so. He went to PCP yesterday, then went to ED
yesterday. He was worked up for SAH. CT and LP done. He was
discharged prior to protein resulting, which ended up being
elevated at 155. He was called back to the ED for further eval
and neurology evaluation.
No positional component to headache. Has not woken up from
sleep.
Same throughout the day. Not worsened by exertion. Not worse
with
coughing or sneezing.
He reports a few fevers/colds in the last month or two, usually
lasts a day or two. He notes that his weight had gone from
around
184->168 in the last 2 months, he fasted for 2 and 3 days on
different occasions during this period and cut calorie intake in
an attempt to lose weight. He felt like the weight loss seemed
proportional to what he was trying to do to lose weight. He
states he has night sweats normally, which can soak sheets, that
at one point his girlfriend put plastic covering under mattress
to try to help with this. His mom at bedside says that this is a
constant issue for him since he was young, he always seems warm.
He says he wears a fall jacket in winter often.
States he traveled to ___ in the last few months but not
travel otherwise. Denies recent bug bites. States he will walk
in
the woods, has done tick checks and hasn't seen anything. He
notes that he feels his R pupil is slightly larger than L.
recently which he has not noticed before.
No back surgeries. He had had some injections around lower back
in college called "prolotherapy." which helped with low back
pain
at the time.
On neurologic review of systems, the patient denies,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
GERD
seasonal allergies
laser correction for eyes
Social History:
___
Family History:
DM
heart disease
thyroid
htn
maternal grandmother had a "weakness in the vessel" resulting in
brain hemorrhage she also apparently had anisocoria her whole
life. passed away at ___ from hemorrhage. pts mother states they
did not say if she had aneurysm.
uncle with GBM
mother with lupus, dx at ___, she had presented with proteinuria,
and had glomerulonephritis
Physical Exam:
Admission:
PHYSICAL EXAMINATION
Vitals: T97.9 HR73 BP140/86 RR18 Spo2 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented ___. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty, quite quickly. Language is fluent with
intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: R>L by 0.5. both briskly reactive. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 2 3 2
R 3 3 2 3 2
suprapatellar present b/l
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Discharge:
24 HR Data (last updated ___ @ 823)
Temp: 98.2 (Tm 98.2), BP: 129/77 (122-129/68-77), HR: 65
(58-65), RR: 18, O2 sat: 96% (96-99), O2 delivery: RA
General: pt is AAOx3, cooperative
HEENT: no scleral icterus, no cervical lymphadenopathy
Lungs: breathing without accessory muscles of respiration
Cardiac: Deferred
Abd: Soft, non-tender, non-distended
Skin: no rashes
Neurological Exam:
Mental Status: Pt is AAOx3, comprehension and memory intact to
course of the interview.
Cranial nerves:
PERRLA 3->2, fully intact extraocular eye movements with no
nystagmus, sensation in the face intact to light touch
bilaterally, no facial muscle weakness bilaterally, tongue
protrudes midline, uvula elevated symmetrically, finger rub
heard
bilaterally, SCM ___ bilaterally
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No asterixis noted.
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch bilaterally
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 2 3 2
R 3 3 2 3 2
Plantar response flexor bilaterally.
Gait: deferred
Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
Pertinent Results:
___ 07:50AM BLOOD WBC-6.5 RBC-4.97 Hgb-15.4 Hct-45.5 MCV-92
MCH-31.0 MCHC-33.8 RDW-12.1 RDWSD-40.1 Plt ___
___ 08:49AM BLOOD WBC-4.5 RBC-5.11 Hgb-16.1 Hct-47.2 MCV-92
MCH-31.5 MCHC-34.1 RDW-12.0 RDWSD-40.8 Plt ___
___ 07:50AM BLOOD Neuts-61.7 ___ Monos-6.5 Eos-0.5*
Baso-0.6 Im ___ AbsNeut-3.99 AbsLymp-1.97 AbsMono-0.42
AbsEos-0.03* AbsBaso-0.04
___ 07:50AM BLOOD Plt ___
___ 08:49AM BLOOD ___
___ 08:49AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-88 UreaN-14 Creat-1.1 Na-146
K-5.0 Cl-103 HCO3-27 AnGap-16
___ 08:49AM BLOOD Glucose-89 UreaN-13 Creat-1.1 Na-145
K-5.0 Cl-103 HCO3-26 AnGap-16
___ 07:50AM BLOOD ALT-16 AST-14 AlkPhos-46 TotBili-0.5
___ 08:49AM BLOOD ALT-15 AST-15 LD(LDH)-168 AlkPhos-48
TotBili-0.7
___ 07:50AM BLOOD Lipase-37
___ 07:50AM BLOOD cTropnT-<0.01
___ 08:49AM BLOOD Calcium-10.8* Phos-3.8 Mg-2.2 UricAcd-6.0
___ 07:50AM BLOOD Albumin-5.0 Calcium-10.6* Phos-3.9 Mg-2.0
___ 08:49AM BLOOD TSH-PND
___ 07:50AM BLOOD ___ CRP-0.9
___ 07:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 07:50AM BLOOD ANGIOTENSIN 1 - CONVERTING ___
PRELIMINARY CTA HEAD AND CTA NECK Study Date of ___ 11:14
AM
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction,hemorrhage,edema,ormass. The
ventricles
and sulci are normal in size and configuration.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches
appear normal without stenosis, occlusion, or aneurysm
formation. The dural
venous sinuses are patent.
CTA NECK:
The carotidandvertebral arteries and their major branches appear
normal with
no evidence of stenosis or occlusion. There is no evidence of
internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized
portion of the
thyroid gland is within normal limits. There is no
lymphadenopathy by CT size
criteria.
PRELIMINARY MR HEAD W & W/O CONTRAST Study Date of ___
6:50 ___
IMPRESSION:
1. Normal brain MRI.
EKG ___
Sinusbradycardia
Vent. rate 59 BPM
PR interval 145 ms
QRS duration 87 ms
QT/QTc 404/401 ms
___ axes 31 66 33
Brief Hospital Course:
In brief, Mr. ___ is a ___ right-handed male with no
significant past medical history who was admitted to the
neurology service after he was found to have an isolated
elevated CSF protein. He originally presented to our emergency
department following an episode of intense headache 5 days
prior. He was evaluated in our ED, had normal vital signs and a
nonfocal exam. A CT/A of the head was unremarkable. A lumbar
puncture was obtained showing no pleocytosis but elevated
protein of 155.
Given this finding he returned to the emergency department and
was admitted for further evaluation. Additional laboratory
studies and MRI of the brain were normal. There is no evidence
for aneurysm, subarachnoid hemorrhage, venous sinus thrombosis,
stroke, neoplasm or other mass lesion.
In retrospect, his presentation with an acute onset thunderclap
headache in the setting of several potential triggers including
exposure to high altitude, exposure to alcohol, physical
activity and the occurrence after sexual organism, raised
concern for RCVS or reversible cerebral vasoconstriction
syndrome. The RCVS2 score was 8.
To prevent future episodes the patient was started on a low-dose
of verapamil. He tolerated his medication without any evidence
of hypotension or symptomatic bradycardia. He will follow-up in
our neurology clinic. Anticipatory guidance and return criteria
reviewed. Patient agreed with the plan.
Medications on Admission:
n.a.
Discharge Medications:
1. Verapamil 40 mg PO Q8H
RX *verapamil 40 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Reversible cerebral vasoconstriction syndrome (or RCVS)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___ Neurology service after you
presented with a sudden-onset headache and were found to have an
elevated protein level in your CSF, a test that was obtained in
our emergency department.
You have had a CT scan and subsequently an MRI of your brain
that did not show any abnormal findings. Except the elevated
protein in your CSF your laboratory tests were within normal
limits.
Overall, we think your presentation is most likely consistent
with a condition called reversible cerebral vasoconstriction
syndrome (or RCVS). RCVS is characterized by a reversible
narrowing of the cerebral arteries leading to an intense
headache, called thunderclap headache. There are several
potential triggers, which in your case may have included
extraneous physical activity, sexual orgasm, exposure to
high-altitude and alcohol.
The diagnosis of RCVS is based on clinical criteria. We started
you on verapamil to prevent future episodes. Please continue
this medication for 1 week post discharge. We will set you up
with follow-up in our neurology clinic.
For questions please call ___.
It was a pleasure taking care of you at ___,
Your ___ neurology team.
Followup Instructions:
___
|
10422455-DS-7 | 10,422,455 | 23,186,865 | DS | 7 | 2146-01-25 00:00:00 | 2146-01-25 19:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever and rigors
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year-old right-handed man with history of tachyarrhythmia
(unclear what type specifically), hyperlipidemia, chronic low
back pain, and anxiety who presents with an episode of rigors,
nausea/vomiting and gait unsteadiness. Currently, the patient
reports being essentially back to his baseline. His neurologic
examination is within normal limits apart from mild right
nasolabial fold flattening at rest, which per review of prior
photographs (including his license photo) is known and not a new
finding.
In the ED, initial VS were Temp 99.2F HR 118 116/67 RR 18 99% RA
Exam in ED not recorded
Labs showed
WBC 6.6 hgb 14.6 plt 153
ALT 15 AST 24 AP 84 Tbili 0.3 Lipase 23 Alb 4.6
Na+ 140 K+ 3.7 BUN 18 Cr 1.0 Glucose 110
Lactate 1.7
Trop <0.01
UA tox opiates pos; neg for benos, barbs, cocaine, amphet,
methdne
UA leuk lg, nitr pos, WBC >182 Bact mod
UCx, BCx pending
EKG NSR HR 93 QTc 437
Imaging showed
___ CT head w/o contrast
No acute intracranial abnormalities. However, MRI would be more
sensitive for detection acute ischemia.
___ CXR
Findings may represent right lower lobe pneumonia in the right
clinical setting.
Received
___ 21:55 IV Ondansetron 4 mg
___ 22:20 IV Ondansetron 4 mg
___ 01:37 IV CefTRIAXone 1 gm
___ 02:33 PO Acetaminophen 1000 mg
___ 02:33 IV Ondansetron 4 mg
___ 03:02 IV Azithromycin 500 mg
___ 03:05 IV Ondansetron 4 mg
___ 03:05 IV Acetaminophen IV 1000 mg
Transfer VS were temp 98.6F HR 104 136/78 RR 20 100% RA
Patient with a history of PNA in ___ otherwise no significant
illness. Patient has not history of chest pain, Negative
stress,
no catheterizations.
Drinks ___ daily daily whiskey 3fingers "drug of choice" also
took klonpin yesterday evening for sleep prescribed by doctor at
___. No history of IVDU denied opiates even though
urine positive.
Neurology was consulted and stated unlikely stroke or TIA. No
meningeal signs of headache next stiffness
On arrival to the floor, patient reports patient drowsy not in
pain. He denies symptoms of pneumonia : no coughor croyza. He
denies symptoms of urinaty tract infection no dysuria burning
stinging with urination. Patient still feeling nauseous and is
drowsy and cognition is foggy
Past Medical History:
___ pneumonia
___ - surgery to repair injury to left hand in machine
operating accident
tachyarrhythmia (unspecified but takes atenolol)
h/o chest pain reportedly negative stress test
HTN
HLD
Social History:
___
Family History:
No history of early cardiac death
otherwise non-contributory
Physical Exam:
Admission Physical Exam
VS: Temp 100.5 PO 113/56 R lying HR 96 RR 18 94% RA
GENERAL: NAD, drowsy
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: tachycardia, S1/S2, no murmurs, gallops, or rubs
LUNGS: Moving air well, course breath sounds on the right base.
no wheezes, rales, rhonchi, breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, hepatomegaly. No splenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical exam
PE
Vitals: 99.3 PO ___ 18 95 Ra
GENERAL: NAD, alert and awake
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD.
HEART: S1/S2, no murmurs, gallops, or rubs
LUNGS: Moving air well, CTAB. no wheezes, rales, rhonchi
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding. Hepatomegaly with no splenomegaly
GU: no CVA tenderness.
RECTAL:
EXTREMITIES: no cyanosis, clubbing, or edema.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission labs
___ 09:50PM BLOOD WBC-6.6 RBC-4.74 Hgb-14.6 Hct-41.5 MCV-88
MCH-30.8 MCHC-35.2 RDW-13.0 RDWSD-41.7 Plt ___
___ 09:50PM BLOOD Neuts-90.0* Lymphs-8.4* Monos-0.6*
Eos-0.5* Baso-0.2 Im ___ AbsNeut-5.90 AbsLymp-0.55*
AbsMono-0.04* AbsEos-0.03* AbsBaso-0.01
___ 09:50PM BLOOD Plt ___
___ 09:50PM BLOOD Glucose-110* UreaN-18 Creat-1.0 Na-140
K-3.7 Cl-102 HCO3-27 AnGap-15
___ 09:50PM BLOOD ALT-15 AST-24 AlkPhos-84 TotBili-0.3
___ 09:50PM BLOOD Lipase-23
___ 09:50PM BLOOD cTropnT-<0.01
___ 09:50PM BLOOD Albumin-4.6
___ 09:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Opiate-POS
___ 11:17PM BLOOD Lactate-1.7
Discharge labs
___ 05:55AM BLOOD WBC-5.0 RBC-4.29* Hgb-13.0* Hct-38.2*
MCV-89 MCH-30.3 MCHC-34.0 RDW-13.5 RDWSD-43.6 Plt Ct-74*
___ 05:55AM BLOOD Plt Ct-74*
___ 05:55AM BLOOD Glucose-78 UreaN-14 Creat-1.0 Na-138
K-4.0 Cl-103 HCO3-23 AnGap-16
___ 05:55AM BLOOD Calcium-8.5 Phos-2.2* Mg-2.1
___ 12:45 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (___) AT
1628 ON
___.
___ 11:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ URINE Legionella Urinary Antigen -FINAL
INPATIENT
___ Rapid Respiratory Viral Screen & Culture
Respiratory Viral Antigen Screen-FINAL; Respiratory Viral
Culture-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
Brief Hospital Course:
========================================
Acute medical/surgical issues addressed
========================================
# Severe sepsis secondary to
# E. coli blood stream infection from primary source as
# Urinary Tract Infection, Complicated
Admitted with encephalopathy which was initially concerning for
possible seizure or TIA however neurological examination by
primary team and neurology were unremarkable. Admission UA was
concerning for a UTI and patient was started empirically in
ceftriaxone. Patient continued to have intermittent fevers
throughout the day. On ___ blood culture returned positive for
gram negative rods and treatment was escalated from ceftriaxone
to cefepime as source at the time was unknown. Patient's
clinical status improved on cefepime and remained afebrile for
remainder of hospitalization. Ultrasound of kidneys was done on
___ and showed a slightly enlarged prostate but no
nephrolithiasis or evidence of pyelonephritis. On ___, urine
and blood cultures returned positive for E. coli sensitive to
ciprofloxacin and transitioned to ciprofloxacin 500mg PO BID.
Source at this time presumed to be from UTI. Prostate exam was
done and prostate was non-tender and non-enlarged. To continue
treatment to complete 14 day course from last negative blood
culture.
#E. Coli UTI
Although patient was asymptomatic, this is likely the source of
bacteremia given that the same organism speciated from both
urine and blood cultures and workup for other causes was
unrevealing. Prostate exam was done and prostate was non-tender
and non-enlarged making prostatitis unlikely.
#Encephalopathy
Initially concern for opiate-induced altered mental status given
positive Utox for opiates. However, patient had history of
eating a substantial amount of poppy seeds a day prior to
admission and based on numerous conversations with patient, wife
and discussion with outpatient providers and pharmacy, the
patient is not using nor has ever used opiates. AMS likely
metabolic encephalopathy in setting of bacteremia. Patient
returned to baseline with resolution in sepsis.
#Thrombocytopenia
Platelet 153 on admission and decreased to nadir at 61 on ___.
Likely a reactive process to gram negative bacteremia, improved
prior to discharge.
==================
Chronic issues
==================
#Hyperlipidemia
Crestor was held during admission but patient to restart on
discharge
#Tachyarrythmia
Patient with regular heart rate during this hospitalization.
====================
Transitional Issues
====================
[ ] Patient to complete a 14 day course of Ciprofloxacin 500mg
PO BID from date of last negative blood culture
[ ] Follow-up pending blood cultures
Medications on Admission:
1. Atenolol 12.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. azelastine 0.15 % (205.5 mcg) nasal DAILY:PRN
4. ClonazePAM 0.5 mg PO BID:PRN anixety
5. Crestor MWF (unclear on dose)
Discharge Medications:
1. Atenolol 12.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. azelastine 0.15 % (205.5 mcg) nasal DAILY:PRN
4. ClonazePAM 0.5 mg PO BID:PRN anixety
5. Crestor MWF (unclear on dose)
Discharge Disposition:
Home
Discharge Diagnosis:
E. coli rod bacteremia
E. coli UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you very much for allowing us to take care of you during
your hospitalization at ___.
While you were in the hospital,
-We found an infection in your bladder and blood and treated you
with antibiotics.
-We did an Ultrasound of your kidneys to search for a cause of
your infection and your kidney's looked normal.
When you leave the hospital, it is important that you continue
to take your antibiotic medication called ciprofloxacin as
prescribed. You will take the medication for 14 days. It is also
important that you follow-up with your primary care physician
within ___ week of leaving the hospital.
Followup Instructions:
___
|
10422699-DS-18 | 10,422,699 | 27,575,223 | DS | 18 | 2147-01-18 00:00:00 | 2147-01-18 14:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx CML maintained recently started on hydroxyurea, CHF,
CABG ___ y ago, pacemaker, now p/w weakness, AMS, diarrhea.
The patinet lives with the daughter and was reportedly normal
until she went to work at on the day PTA at 1pm. When the son
came over later he found the pt confused, with diarrhea
everywhere. The patient does not recall having been confused.
The patient then fell while in the bathroom with his son-in-law
and hit himself between his shoulder blades. The son-in-law
denied any head trauma or LOC. No seizure like activity was
noted. The patient denies neck pain, fevers or chills. ROS is
further negative for fever, vomiting, abd pain, black or bloody
stool.
Of note, the patient was recently started on lasix 20mg daily
for edema. He reported urinary frequency recently as well but
denies urgency or dysuria. The patient denies any recent
antibiotics. He denies any sick contacts and reports that he has
not eaten out in a long time.
ED Course (labs, imaging, interventions, consults): VS initially
HR 80, RR: 15, BP: 122/64, O2Sat: 96% RA. Temperature was noted
to be 103.2. A CT abdomen was done which was unremarkable on
wet-read. Labs were notable for an elevated WBC at 11.8 with
left-shift. Platelets were decreased at 38 compared to prior.
The patient was given vancomycin and Zosyn. On transfer to the
floor, VS: 122/64, 96% RA, 82 AV paced (hx aflutter), 18 RR,
98.4.
Review of Systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies blurry vision, diplopia, loss of vision, photophobia.
Denies headache. Denies chest pain or tightness, jaw pain,
palpitations, lower extremity edema. Denies cough, shortness of
breath, or wheezes. Denies nausea, vomiting, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria. Denies
arthralgias or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. All other systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
CHRONIC MYELOGENOUS LEUKEMIA -
He has previously been treated with interferon, hydroxyurea,
followed by Gleevec plus hydroxyurea. He has developed
resistance to Gleevec and was started on dasatinib in ___.
Because of prolonged QT interval with dasatinib and some
significant cardiac complications, the drug was discontinued.
However, as there was no alternative that was likely to be
effective, the patient had a pacemaker placed and then was
restarted on dasatinib. Unfortunately, after a short period on
dasatinib (dose 70 mg b.i.d.), his white count had fallen to
normal. His hematocrit had also fallen to the ___ range and
his platelet count had fallen to less than 20,000 requiring
hospitalization and transfusion. He was off dasatinib for a few
weeks. However, after his platelets climbed to greater than
100,000, he resumed dasatinib at a reduced dose of 70 mg a day
but after a few weeks, had to again hold the drug related to
thrombocytopenia. He resumed Sprycel at 50 mg a day in ___,
three weeks later, he subsequently stopped the drug again when
he had a fall and was found to have rhabdomyolysis as well as
thrombocytopenia and anemia. His Zocor was held. He has had
admits with TIAs and is followed by his PCP, ___, and general
psych. He is currently back on Sprycel at one 50mg tab once per
day.
PAST MEDICAL HISTORY:
S/P TRANSIENT ISCHEMIC ATTACK
COMPLETE HEART BLOCK - pacemaker
CORONARY ARTERY DISEASE, s/p 5 vessel cabg ___
DERMATOLOGIC SURGERY ___
HYPERLIPIDEMIA
HYPERTENSION
INGUINAL HERNIA
PERIPHERAL EDEMA
h/o PNEUMONIA
RENAL INSUFFICIENCY, stage IV chronic kidney disease of somewhat
unclear etiology, probably related to hypoperfusion and possibly
past nephrotoxin exposure, baseline creatinine 3.0
RETINAL VASCULAR OCCLUSION
Hearing impaired
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had Pulmonary ___ in her late ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T:97.5 BP:124/70 HR:81 RR:18 02 sat:100RA
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, scars
from prior skin ca surgery; excoriations on the back
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM, nontender
supple neck, no LAD, no JVD; tongue bite on the left
CARDIAC: RRR, ___ holosystolic murmur; mild diastolic murmur
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, 2+ edema b/l
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact; ___ strength in upper arms; ___ in
lower extremities
Pertinent Results:
Pertinent Labs:
___ 10:35AM BLOOD WBC-10.1# RBC-3.56* Hgb-9.2* Hct-29.7*
MCV-83 MCH-25.7* MCHC-30.8* RDW-18.7* Plt Ct-39*
___ 10:35AM BLOOD Neuts-76* Bands-0 Lymphs-17* Monos-4
Eos-0 Baso-2 ___ Myelos-1*
___ 06:50PM BLOOD WBC-11.8* RBC-3.52* Hgb-8.9* Hct-29.7*
MCV-84 MCH-25.4* MCHC-30.1* RDW-19.4* Plt Ct-38*
___ 06:00AM BLOOD WBC-8.4 RBC-3.03* Hgb-7.7* Hct-25.4*
MCV-84 MCH-25.4* MCHC-30.4* RDW-18.9* Plt Ct-32*
___ 01:10PM BLOOD WBC-6.7 RBC-2.86* Hgb-7.4* Hct-24.0*
MCV-84 MCH-25.9* MCHC-30.9* RDW-19.1* Plt Ct-30*
___ 07:10AM BLOOD WBC-5.4 RBC-3.26* Hgb-8.7* Hct-28.2*
MCV-86 MCH-26.8* MCHC-31.0 RDW-19.7* Plt Ct-41*
___ 07:08AM BLOOD WBC-4.3 RBC-3.21* Hgb-8.6* Hct-27.0*
MCV-84 MCH-26.8* MCHC-31.8 RDW-20.0* Plt Ct-31*
___ 06:50PM BLOOD ___ PTT-25.3 ___
___ 07:10AM BLOOD ___ PTT-29.1 ___
___ 11:30AM BLOOD UreaN-66* Creat-3.3* Na-136 K-4.0 Cl-102
HCO3-21* AnGap-17
___ 06:50PM BLOOD Glucose-132* UreaN-63* Creat-2.9* Na-136
K-3.8 Cl-103 HCO3-19* AnGap-18
___ 06:00AM BLOOD Glucose-90 UreaN-59* Na-135 K-3.5 Cl-106
HCO3-18* AnGap-15
___ 07:10AM BLOOD Glucose-89 UreaN-47* Creat-2.8* Na-136
K-3.5 Cl-106 HCO3-17* AnGap-17
___ 07:08AM BLOOD Glucose-87 UreaN-44* Creat-2.7* Na-135
K-3.8 Cl-105 HCO3-19* AnGap-15
___ 11:30AM BLOOD ALT-20 AST-33 AlkPhos-143* TotBili-0.4
___ 06:50PM BLOOD ALT-17 AST-32 CK(CPK)-257 AlkPhos-124
TotBili-0.4
___ 07:10AM BLOOD ALT-12 AST-21 LD(LDH)-281* AlkPhos-95
TotBili-0.4
___ 11:30AM BLOOD Lipase-27
___ 06:50PM BLOOD Lipase-29
___ 11:30AM BLOOD cTropnT-0.07* proBNP-8918*
___ 06:50PM BLOOD CK-MB-6 proBNP-9916*
___ 06:50PM BLOOD cTropnT-0.06*
___ 06:00AM BLOOD CK-MB-5 cTropnT-0.07___ 06:50PM BLOOD Albumin-3.8 Calcium-8.6 Phos-5.0* Mg-2.1
___ 07:10AM BLOOD Albumin-3.3* Calcium-8.4 Phos-3.7 Mg-2.0
UricAcd-8.6*
___ 07:08AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.9
___ 06:56PM BLOOD Lactate-1.6
URINE:
___ 08:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:20PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 08:20PM URINE RBC-6* WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
MICRO:
Urine cx ___: no growth
blood cx (x2) ___: no growth to date
c. diff ___: negative
STUDIES:
ECG (___): rate 79. Atrial and ventricular sequential pacing.
Compared to the previous tracing of ___ there is no
significant change.
CXR (___):
IMPRESSION:
1. Moderate cardiomegaly.
2. Vascular engorgement/early pulmonary edema.
CT abd pelvis non-contrast (___):
IMPRESSION:
1. No CT evidence for acute intra-abdominal or pelvic process on
this
non-contrast-enhanced exam.
2. Bilateral pleural effusions, left greater than right.
3. Diffuse subcutaneous and mild mesenteric edema.
CT head non-contrast (___):
IMPRESSION:
1. No acute intracranial process.
2. Mild-to-moderate global atrophy with evidence of chronic
microvascular
ischemic disease.
3. Findings consistent with right maxillary sinusitis.
Brief Hospital Course:
Brief clinical summary:
___ yo male with CML on dasatinib and recently started on
hydroxyurea, presenting with fever and diarrhea. Patient's
diarrhea and fevers resolved with cipro and flagyl. No
infectious agent isolated. Will continue for 5d course of abx.
# Fever and Diarrhea: acute onset and fever occured on day of
admission. no source identified. c. diff negative. after
arrival to floor, no additional fevers or diarrhea. the patient
was started on ciprofloxacin and flagyl, and will continue for a
five day total course. CT abd/pelvis demonstrated no e/o
infectious source. the patient was also reported to be altered
at home, but this resolved quickly after arrival to hospital.
the patient was hydrated gently with IVF on Day 1 of
hospitalization. urine culture was negative, blood culture was
no growth to date by time of discharge. the patient had a small
bruise on back of head from falling at home in relation to his
diarrhea. ct head non-contrast demonstrated no acute
intracranial abnormality. the patient was able to walk with ___
prior to discharge.
# CML: continued hydroxyurea. primary oncologist Dr. ___
patient upon arrival to ___ service. patient has follow-up with
Dr. ___ on ___.
# CAD/CHF/Lower extremity edema: component of CHF and
inactivity; no clinical evidence for ischemia. mild tropinemia
likely secondary to chronic renal insufficiency. continued
Furosemide 20mg Qday
# Chronic renal disease: creatinine 3.0 upon admission, with Cr
decreasing to 2.7 by day of discharge, which is patient's
baseline. continued calcitriol, Vit D
# Hypothryoidism: continued Levothyroxine
Transitional Issues:
1. f/u final blood cultures
2. ___ f/u appt w/ Dr. ___
___ on Admission:
calcitriol 0.25 mcg Capsule -1 Cap every Mo, ___ and ___
furosemide 20 mg Tablet every day as needed
hydroxyurea 1000 mg alternating with 500mg daily
levothyroxine 12.5 mcg Tablet QD
metoprolol succinate 50 mg 1 tab once a day
mupirocin 2 % Ointment apply to wound
simvastatin 20 mg Tablet Qday
aspirin 81 mg
vitamin D3 1,000 unit once a day
cyanocobalamin (vitamin B-12)
docusate sodium 100 mg Capsule BID as needed for constipation
sodium bicarbonate 650 mg Tablet 2 tab BID
Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day): Every ___.
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Take as prescribed.
3. hydroxyurea 500 mg Capsule Sig: ___ Capsules PO EVERY OTHER
DAY (Every Other Day): Take 1000mg alternating with 500mg. Due
for 500 mg on ___.
4. levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
9. cyanocobalamin (vitamin B-12) Oral
10. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation: hold for loose stool.
12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 3 days: last day of antibiotics ___.
Disp:*9 Tablet(s)* Refills:*0*
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: last day of antibiotics ___.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis:
diarrhea
secondary diagnosis:
CML
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you.
You were admitted to the ___
for a fever and diarrhea.
We performed a CT scan and cultures to determine whether you
have an infection. We found no evidence of infection on these
studies. We also treated you with antibiotics. Your fevers and
diarrhea resolved.
We have made the following changes to your medication regimen:
ADD ciprofloxicin by mouth once per day, final day ___
ADD flagyl by mouth every 8 hours, final day ___
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10422699-DS-19 | 10,422,699 | 28,659,484 | DS | 19 | 2147-02-04 00:00:00 | 2147-02-04 16:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an ___ year old male with a history of CML, CAD
s/p five vessel CABG, complete heart block with PPM, and CKD
Stage 4 who presents after an unwitnessed fall at home. ___
apparently fell this morning around 7:30 AM in the kitchen. ___
says that ___ was trying to stand up from a chair when ___ fell.
___ does not recall having any prodromal symptoms, and denies any
loss of consciousness. ___ was found within a few minutes and
was conscious.
Per his family, ___ has been more confused over the last three
days. At baseline, ___ is nearly independent in his ADLs, but
does have considerable help from his daughter. ___ is usually
fully oriented and conversant. His family thinks that ___ has
been more confused since starting Hydroxyurea, and may have had
trouble with it in the past as well. In the ED, ___ was
initially A+Ox1 and had trouble following instructions. ___
denied pain anywhere despite his fall with significant flank
bruising. ___ denied recent CP, SOB, nausea, vomiting, or
diarrhea. Of note, ___ was recently admitted from ___ to
___ for fever and diarrhea, and was treated with
Ciprofloxacin and Flagyl. The diarrhea completely resolved
shortly after discharge.
In the ED, initial vitals were T 99.3, HR 80, BP 175/88, RR 16,
and SpO2 98% on RA. Physical exam showed a large ecchymosis
from the right axilla to the buttock and diffuse tenderness from
the T-spine to the sacrum, but intact strength in all
extremities. CBC was significant for Hct 28.8 near recent
baseline, Plt 70, and WBC 9.4. Chem panel was notable for Cr
3.0 near baseline, bicarb 16, anion gap 15, and lactate 0.8.
Straight cath initially produced frank blood, but this soon
cleared. CXR showed pulmonary edema. CT head and neck showed
no intracranial bleed or fracture. CT torso showed a likely LUL
pneumonia.
___ spiked a fever to 102.3 rectally in the ED, and became more
confused. ___ was given normal saline 1000 ml, and started on
Vancomycin and Zosyn for HCAP coverage. ___ was admitted to the
___ service for further management. Vitals prior to floor
transfer were T 101.2, HR 84, BP 135/69, RR 18, and SpO2 100% on
2L. On reaching the floor, ___ reported being thirsty, but
denied any other current complaints. Per his family, ___ was
less confused, but still far from his prior baseline.
Past Medical History:
# CHRONIC MYELOGENOUS LEUKEMIA
-- multiple prior treatment regimens
-- switched from Dasatinib to Hydroxyurea ___
PAST MEDICAL HISTORY:
# S/P TRANSIENT ISCHEMIC ATTACK
# COMPLETE HEART BLOCK -- pacemaker
# CORONARY ARTERY DISEASE -- s/p 5 vessel CABG (___)
# HYPERLIPIDEMIA
# HYPERTENSION
# INGUINAL HERNIA
# PERIPHERAL EDEMA
# CKD Stage IV -- baseline creatinine 3.0
-- etiology unclear, possibly from prior episodes of
hypoperfusion and nephrotoxin exposure
# RETINAL VASCULAR OCCLUSION
# Hearing impaired
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had pulmonary emboli in her late ___.
Physical Exam:
VS: T 98.2, BP 142/76, HR 80, RR 20, SpO2 100% on 3L, Wt 131.3
lbs
GENERAL: NAD, thirsty, alert, oriented to person, ___
___", year ___, month ___
SKIN: fingers somewhat cool with slow capillary refill, chronic
per patient, chronic venous stasis changes on LEs with some
scaling and area of prior skin graft, no evidence of acute
infection
HEENT: EOMI, PERRL, anicteric sclera, right lateral sclera with
area of hemorrhage, pink conjunctiva, patent nares, MMM, OP
benign
NECK: nontender supple neck, no LAD, JVD to mid neck
CARDIAC: RRR, S1/S2, harsh holosystolic murmur at RSB and base
without radiation
LUNG: CTAB except for a few crackles in left anterior lung field
ABDOMEN: soft, nondistended, BS present, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXT: moving all extremities well, ___ edema 1+ bilaterally
PULSES: 2+ radial and 1+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in all extremities both
proximally and distally, sensation intact to light touch in
distal extremities
Pertinent Results:
ADMISSION LABS
___ 09:20AM BLOOD WBC-6.8 RBC-3.44* Hgb-9.6* Hct-31.1*
MCV-90 MCH-28.1 MCHC-31.1 RDW-21.7* Plt Ct-69*#
___ 09:20AM BLOOD Neuts-48* Bands-0 ___ Monos-17*
Eos-3 Baso-6* ___ Myelos-1*
___ 09:20AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-2+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Target-OCCASIONAL
Burr-OCCASIONAL Tear Dr-OCCASIONAL
___ 09:20AM BLOOD Plt Smr-VERY LOW Plt Ct-69*#
___ 11:16AM BLOOD ___ PTT-30.6 ___
___ 11:16AM BLOOD Glucose-90 UreaN-48* Creat-3.0* Na-133
K-4.4 Cl-100 HCO3-16* AnGap-21*
PERTINENT STUDIES AND LABS
___ 11:16AM BLOOD CK(CPK)-106
___ 06:20AM BLOOD CK(CPK)-123
___:16AM BLOOD CK-MB-2 cTropnT-0.07*
___ 11:16AM BLOOD cTropnT-<0.01
___ 06:20AM BLOOD CK-MB-2 cTropnT-0.08*
___ 06:20AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.1
___ 11:00AM BLOOD VitB12-GREATER TH
___ 11:16AM BLOOD TSH-6.9*
___ 11:16AM BLOOD Free T4-1.0
___ 05:40AM BLOOD Vanco-6.7*
___ 10:30AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:20AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 11:15AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:40AM BLOOD WBC-13.8* RBC-3.39* Hgb-9.4* Hct-30.1*
MCV-89 MCH-27.8 MCHC-31.3 RDW-22.2* Plt Ct-88*
___ 05:40AM BLOOD Neuts-64 Bands-0 Lymphs-14* Monos-21*
Eos-0 Baso-0 ___ Myelos-1*
___ 05:40AM BLOOD Glucose-89 UreaN-47* Creat-3.2* Na-133
K-4.1 Cl-101 HCO3-16* AnGap-20
___ URINE Legionella Urinary Antigen -NEGATIVE
___ RAPID PLASMA REAGIN TEST-NEGATIVE
___ BLOOD CULTURE PENDING
___ BLOOD CULTURE PENDING
___ URINE CULTURE NO GROWTH
___ CXR moderate pulmonary edema.
___ CT C Spine
1. No fractures. Multilevel degenerative changes.
2. Severe atherosclerosis.
3. Pulmonary edema, better evaluated on accompanying CT torso.
___ ct head without contrast
1. No fractures or intracranial hemorrhage.
2. Chronic involutional changes.
3. Maxillary sinus disease.
___ CT Chest, Abd, Pelvis
1. No fractures or hematomas.
2. Emphysema and pulmonary edema. New left upper lobe
aspiration or
infection.
3. Moderate cardiomegaly and anemia.
4. Severe atherosclerosis and infrarenal aortic ectasia.
DISCHARGE LABS
___ 06:40AM BLOOD WBC-15.8* RBC-3.31* Hgb-9.2* Hct-29.6*
MCV-90 MCH-27.6 MCHC-30.9* RDW-22.1* Plt ___
___ 06:40AM BLOOD Neuts-48* Bands-2 Lymphs-8* Monos-35*
Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-1* Promyel-1* Other-2*
___ 06:40AM BLOOD Plt Smr-LOW Plt ___
___ 06:40AM BLOOD Glucose-78 UreaN-43* Creat-3.1* Na-136
K-3.4 Cl-103 HCO3-17* AnGap-19
___ 06:40AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0
___ 06:32PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Brief Hospital Course:
The patient is an ___ year old male with a history of CML, CAD
s/p five vessel CABG, complete heart block with PPM, and CKD
Stage 4 who presents after an unwitnessed fall at home, spiking
a fever to 102.3 in the ED and having CT chest findings
concerning for LUL pneumonia. ___ was treated with IV
zosyn/vancomycin and defervesced, then transitioned to
cefpodoxime/azithromycin to complete a full course.
ACUTE CARE
# Unwitnessed Fall: Based on his description of the event, his
fall is likely either mechanical in the setting of ongoing
confusion, or orthostatic related to his infection, but
orthostatics were negative during his hospitalization. However,
___ does not fully remember the episode. Seizure seems unlikely
given his lack of seizure history. Cardiogenic is possible, but
___ neg and pacer currently working with rates in the ___. No
events on tele. ___ evaluated the patient and recommended rehab.
# Confusion: His presentation with increased confusion is likely
multifactorial delirium from fever, infection, fall with head
strike, and it improved after antibiotics, IVF, defevervesced.
However, his family was concerned that ___ has been off his
baseline for several weeks and were concerned that ___ had a
stroke. A family meeting in which discussion of the possibility
of stroke despite negative CT head, but given his current
condition and the inability to treat if embolic given his
thrombocytopenia and risk of bleeding, further investigation
would not help at this time, and the patient cannot get MRI with
pacemaker in place, to which his family agreed. ___ had no focal
neurologic findings on exam. His TSH was also mildly elevated at
6.9 w/ free T4 of 1; since hypothyroidism could contribute to
his confusion, his levothyroxine dose was increased to 25mcg.
# Fever/Leukocytosis: His CT chest is concerning for a LUL
pneumonia. So, pna is most likely cause of his symptoms.
Initially treated for HAP with vanco/zosyn given recent hospital
admission on ___ for fever and diarrhea. ___ denies having
diarrhea at this time. No abd pain. Another possible cause of
his fever and increase in WBC is his CML. ___ was transitioned to
azithromycin and cefpoxodime for outpt treatment.
# CKD Stage 4: Creatinine at 3.1 on discharge. Continue
Calcitriol, Vitamin D, and Sodium bicarbonate. held Lasix 20mg
PO qday at admission and this resulted in improved Cr. We
recommend cont to hold it and re-starting it based on daily
weights, if the patient gains 3LBS, please consider re-starting
Lasix. Otherwise, ___ did not have crackles on lung exam at time
of d/c and ___ edema was only trace.
CHRONIC CARE
# CML: Mulitple regimens used in past. Recently switched from
Dasatinib to Hydroxyurea last month, with dose reduction last
week. Continued on Hydroxyurea 500 mg PO DAILY.
# Pulmonary Edema: His CXR and CT in the ED showed pulmonary
edema, and ___ has chronic ___ edema. His last TTE on ___
showed mildly decreased LVEF 40%, severe TR, and moderate MR.
___ maintained SpO2 in the high ___. Cont on Lasix at home dose
of 20mg.
# Hypothyroidism: Increase in TSH to 6.9 and free T4 at 1, so
increased dose from 12.5-> 25mcg. Will need repeat levels in ___
weeks
# CAD: No current chest pain or concerning findings on EKG,
though evaluation limited by paced rhythm. Aspirin was held on
___ for low platelets. Trop at 0.07-0.08 which is his
baseline given prior admission. Flat CK-MB, ___ denies having any
chest discomfort. ASA was held given thrombocytopenia, continue
Simvastatin 20 mg PO daily, substituted Metoprolol 25 mg PO BID
for home long acting.
TRANSITIONS OF CARE
# CODE: Discussion with family and ___ attending, ___ is DNR/DNI
# EMERGENCY CONTACT: ___ (daughter, Phone:
___, Cell: ___
# PENDING STUDIES: Blood culture x2
# ISSUES TO ADDRESS AT FOLLOW UP
- resolution of pneumonia
- completion of abx
- recheck TFTs in a ___ weeks.
- address resuming lasix (held at time of d/c given incr in Cr,
no crackles on lung exam and only mild ___ edema)
Medications on Admission:
Hydroxyurea 500 mg PO DAILY
Aspirin 81 mg PO DAILY -- On hold
Simvastatin 20 mg PO DAILY
Metoprolol succinate 50 mg PO DAILY
Furosemide 20 mg PO daily PRN edema
Sodium bicarbonate 650 mg 2 tabs PO BID
Calcitriol 0.25 mcg PO on ___, and ___
Vitamin D3 1000 units PO DAILY
Levothyroxine 12.5 mcg PO DAILY
Docusate 100 mg PO BID PRN constipation
Mupirocin 2% Ointment
Vitamin B12
Discharge Medications:
1. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK
(___).
6. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
7. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. Vitamin B-12 Oral
10. mupirocin 2 % Ointment Topical
11. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 5 days.
12. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 doses. Tablet(s)
13. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: Two
(2) Drop Ophthalmic PRN (as needed) as needed for dry eyes.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
primary diagnosis:
health care associated pneumonia
chronic myelogenous leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted and found to have a pneumonia. You are being
discharged on antibiotics.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please be sure to note the following changes to your
medications:
- START azithromycin for 3 more days
- START cefpodoxime for 5 more days
- INCREASE levothyroxine
- STOP Lasix for now but discuss restarting with your
physicians.
- You may use eyedrops for dry eye if you would like.
Followup Instructions:
___
|
10422808-DS-18 | 10,422,808 | 27,726,881 | DS | 18 | 2122-04-12 00:00:00 | 2122-04-13 10:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
ORIF of R acetabulum fracture
History of Present Illness:
___ male presents with right hip pain and the sensation
of
subluxing since falling onto his extended RLE in a ditch while
chasing his dog last ___. At the time he felt immediate
pain
but continued to weight bear with a limp over the ensuing days.
He notes several subsequent episodes in which he felt that the
hip slid out of joint. Denies other injuries. No numbness or
tingling in the lower extremities.
Past Medical History:
Migraines
Social History:
___
Family History:
Noncontributory
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Incision clean/dry/intact with no erythema or discharge, minimal
ecchymosis
Right lower extremity fires ___
Right lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Right lower extremity warm and well perfused
Pertinent Results:
Please see OMR for pertinent lab/radiology data.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R acetabulum fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF of R acetabulum fracture, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch-down weight bearing in the right lower extremity, and will
be discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
Excedrin migraine
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Use Oxycodone for pain not relieved by Acetaminophen.
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*100 Tablet Refills:*1
2. Diazepam 5 mg PO Q12H:PRN muscle spasms
Don't take before or while driving, operating machinery, or with
alcohol.
RX *diazepam 5 mg 1 tablet(s) by mouth every 12 hours as needed
Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Hold for diarrhea or loose stools.
RX *docusate sodium [Colace] 100 mg 2 capsule(s) by mouth twice
daily Disp #*80 Capsule Refills:*1
4. Enoxaparin Sodium 40 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
Take for 4 weeks to prevent blood clots.
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneously daily Disp
#*26 Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Don't take before or while driving, operating machinery, or with
alcohol.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*60 Tablet Refills:*0
6. Senna 8.6 mg PO BID
Hold for diarrhea or loose stools.
RX *sennosides [senna] 8.6 mg 2 tablets by mouth every evening
Disp #*40 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
R acetabulum fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch-down weightbearing of Right lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks post-operatively to
prevent blood clots.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Followup Instructions:
___
|
10422904-DS-7 | 10,422,904 | 20,462,709 | DS | 7 | 2184-01-30 00:00:00 | 2184-01-31 17:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old F, history of rheumatoid arthritis on
cyclosporine, azathioprine, hydroxychloroquine, who presents
with
fever for the last 3 days. Patient has been experiencing fevers
for past 3 days at home, which have been recorded up to 103 °F.
She has reduced p.o. intake, worsened chronic abdominal pain
(described below) and shortness of breath with fevers. Fevers
are
responsive to Tylenol. Of note, patient fever curve has been
downtrending for past 3 days measured at 103, 101, 100
(approximately) each day. Denies cough, sputum, urinary
frequency, dysuria, myalgias, rash however endorses dyspnea on
exertion. ROS otherwise notable for weight loss, specifically
being down from 144 lbs from 155 ___ years ago as well as
worsening of chronic abdominal pain as described below:
Patient has been experiencing RUQ pain for approximately ___ year.
Reports the pain is epigastric, 5 out of 10 in severity,
associated with food approximately ___ hours after eating, no
bowel movement association, improved with Tylenol. Patient has
been seeing outpt GI, who prescribed omeprazole BID regimen with
little clinical improvement. Travel history notable for trip to
___ six months ago. Has hx of H pylori, however, recent EGD in
___ was unremarkable. Patient was ordered for outpatient
RUQUS and CT A/P which were completed prior to presentation in
the ED earlier today.
Past Medical History:
Rheumatoid Arthritis: Diagnosed ___ years ago, previously on
methotrexate, transitioned to azathioprine in ___ of this
year.
Social History:
___
Family History:
There is a family history of osteoporosis, asthma, and renal
disease as well as history of arthritis and thyroid disease.
Her husband recently diagnosed with H. pylori infection as well
as gastric cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.7' BP: 115/65; HR: 67; O2: 99
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. EOMI
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No increased work of
breathing..
ABDOMEN: Normal bowels sounds, non distended, mild epigastric
tenderness appreciated
EXTREMITIES: WWP, no edema
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 1151)
Temp: 98.4 (Tm 98.7), BP: 100/64 (100-121/62-70), HR: 67
(65-67), RR: 20 (___), O2 sat: 97% (97-99), O2 delivery: RA,
Wt: 142.64 lb/64.___ Temp: 98.7 PO
___ 2327 Temp: 97.7 PO
___ 0718 Temp: 98.3 PO
___ 1151 Temp: 98.4 PO
GEN: NAD
HEENT: NO LAD
CV: rrr, no g/m/r
PULM: CTAB, no wheeze, no crackles
ABD: bowel sounds present, TTP over the epigastrium, no rebound,
no guarding
EXT: WWP, 2+ radial pulses
DERM: No rashes.
Pertinent Results:
ADMISSION LABS
___ 03:00PM BLOOD WBC-2.8* RBC-4.37 Hgb-13.9 Hct-41.6
MCV-95 MCH-31.8 MCHC-33.4 RDW-13.2 RDWSD-46.0 Plt ___
___ 03:00PM BLOOD Neuts-54.1 ___ Monos-7.8
Eos-11.3* Baso-0.7 Im ___ AbsNeut-1.53* AbsLymp-0.72*
AbsMono-0.22 AbsEos-0.32 AbsBaso-0.02
___ 03:00PM BLOOD Glucose-129* UreaN-13 Creat-0.9 Na-135
K-4.1 Cl-102 HCO3-20* AnGap-13
___ 12:05PM BLOOD ALT-195* AST-144* AlkPhos-203* Amylase-68
TotBili-0.4
___ 03:00PM BLOOD calTIBC-274 TRF-211
___ 03:00PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 11:12AM BLOOD Cyclspr-<30*
___ 03:00PM BLOOD HCV Ab-NEG
DISCHARGE LABS
___ 10:20AM BLOOD WBC-3.2* RBC-4.67 Hgb-14.6 Hct-44.6
MCV-96 MCH-31.3 MCHC-32.7 RDW-13.5 RDWSD-46.9* Plt ___
___ 10:20AM BLOOD Neuts-45.1 ___ Monos-6.3 Eos-5.3
Baso-0.9 Im ___ AbsNeut-1.43* AbsLymp-1.34 AbsMono-0.20
AbsEos-0.17 AbsBaso-0.03
___ 10:20AM BLOOD Glucose-124* UreaN-10 Creat-0.8 Na-140
K-4.8 Cl-105 HCO3-26 AnGap-9*
___ 10:20AM BLOOD ALT-127* AST-40 LD(LDH)-208 AlkPhos-178*
TotBili-0.3
IMAGING
___ RUQ US
1. Bilateral renal peripelvic cysts with no hydronephrosis.
2. No cholelithiasis, intra or extrahepatic biliary ductal
dilation.
___ CT ABD & PELV
1. No etiology for the patient's pain identified. No evidence
of inflammatory bowel disease or obstruction
2. 5 mm noncalcified lung nodule. CT follow-up in 12 months in
a high risk patient can be considered
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule smaller than 6 mm, no CT follow-up is
recommended in a low-risk patient, and an optional CT in 12
months is recommended in a high-risk patient.
Brief Hospital Course:
ADMISSION
=========
___ F w/ rheumatoid arthritis on cyclosporine, azathioprine, and
hydroxychloroquine, presenting with fever, epigastric pain and
elevated transaminases.
ACUTE ISSUES
============
# Azathioprine Adverse Effect
# Fever
# Transaminitis
Prior to admission, patient had home T-max of 103, one day of
night sweats and nasal congestion. During her hospital course,
she was afebrile, normotensive and non-tachycardic. She had
recently started azathioprine at her last outpatient
rheumatology appointment with Dr. ___ on ___
and was meant to follow-up with outpatient labs. Her symptoms
and labs were felt to be consistent with a viral infection
(EBV,CMV). Azathioprine was held on admission, WBC count
uptrended and she remained hemodynamically stable with no
signs/symptoms of infection. She will be written for outpatient
labs, and is to follow-up with ___ Rheumatology on ___ at
which time her RA regimen can be discussed.
# Leukopenia
Suspect this is related to her azathioprine toxicity which
possibly predisposed her to infection. Improved after holding
azathioprine. Will discharge her off of azathioprine with plans
to follow up with repeat labs and rheum follow up as outpatient.
# Relative ___
She presented with a lymphopenia with relative eosinophilic
predominance. Her eosinophilia was mild; and absolute eos were
not elevated above standard range. She has several risk factors
for helminth infection (international travel, suppression), and
if differential continues to be abnormal, would recommend
checking for strongyloides or other parasitic infections endemic
to ___.
# Abdominal pain
She presented with abdominal pain that was chronic. CT A/P as
well as RUQ US was unrevealing for any structural abnormality to
explain her symptoms. She had a recent EGD ___ that showed an
irregular z-line but otherwise no concerning features. Abdominal
pain stable and patient able to tolerate po intake.
CHRONIC ISSUES
==============
#Osteoporosis
-Continue alendronate 70 mg weekly
#RA
- Hold azathioprine 50 mg daily
- Cont hydroxychloroquine 200
TRANSITIONAL ISSUES
===================
[] Follow-up in 1 week for LFTs and CBC w/ differential
[] Follow-up with ___ Rheumatology re: restarting azathioprine
[] If eosinophilia/transaminitis persists, would check for
alternative infectious etiologies including strongyloides.
#CODE: Full
#CONTACT: ___
#DISPO: Medicine, likely d/c tomorrow
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Alendronate Sodium 70 mg PO Frequency is Unknown
2. AzaTHIOprine 50 mg PO DAILY
3. Hydroxychloroquine Sulfate 200 mg PO BID
4. Omeprazole 20 mg PO BID
5. Vitamin D ___ UNIT PO DAILY
6. CycloSPORINE (Sandimmune) Dose is Unknown PO Q12H
Discharge Medications:
1. Alendronate Sodium 70 mg PO 1X/WEEK (___)
2. Hydroxychloroquine Sulfate 200 mg PO BID
3. Omeprazole 20 mg PO BID
4. Vitamin D ___ UNIT PO DAILY
5.Outpatient Lab Work
ICD10 Drug Reaction (T50.905A)
AST, ALT, AlkPhos, CBC w/ Diff
Fax results to:
ATTN: Dr. ___ MD, ___
___ ___
___
Discharge Disposition:
Home
Discharge Diagnosis:
#Viral Infection
#Drug Adverse Effect
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why did you come to the hospital?
- You were admitted to the hospital because you had fevers and
abnormal blood labs
What happened you were in the hospital?
- We stopped one of your medications, azathioprine. Your
Rheumatologist will help you decide whether to restart this.
What should you do once you leave the hospital?
- Take all of your medications as prescribed.
- Make sure to follow up with your primary care doctor.
- Make sure to follow up with your rheumatologist.
- STOP taking the azathioprine. Do not resume until you are told
so by a doctor.
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10423783-DS-21 | 10,423,783 | 27,082,127 | DS | 21 | 2123-06-04 00:00:00 | 2123-06-04 16:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
alendronate sodium
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
ORIF left hip
History of Present Illness:
Ms. ___ is a ___ year old female with a history of HTN,
HLD, OA and hypothyroidism presenting from an OSH for evaluation
of left hip fracture and SAH - now s/p ORIF and being
transferred to medicine service because of SVT at OSH. Patient
fell on ___ and was found by her family - likely was down for
hours. Events surrounding fall are unclear. At OSH, CT head
showed rt parietal/occipital SAH. She is not on anticoagulation
other than aspirin. Pelvic x-ray showed a left intertrochanteric
fracture. At the OSH she had an episode of SVT with rates in the
170s - was given 6 mg adenosine and 10 mg IV dilt with
resolution. She was transferred to ___ for Nsurg/ortho eval.
In our ED she had a repeat head ct that did not show any change.
She also had a CT c-spine that did not show any acute fracture.
Upon admission, she was seen both by ortho and neurosurgery and
went to the OR for ORIF which was only complicated by
significant post procedure HCT drop (8 points) . She was
initially admitted to the SICU out of concern for SVT, but was
able to proceed with surgery. Neurosurgery felt her SAH was
stable and has no plans for operative intervention - they
recommend f/u in 4wks and using SQH for DVT ppx rather than
lovenox. Post-op, her Hct dropped from 29.6 to 21.9 in the PACU
- she was transfused 2U PRBC and repeat Hct 32. She was then
sent to the floor.
Currently, the patient is resting comfortably. On nightfloat use
of translator line was attempted with minimal success. This AM
attempted to use translator line however patient kept repeating
names of family members when asked questions.
This AM, patient had fall, no evidence of headstrike. No
evidence of trauma to head and face, no appreciable increase in
pain. Ordred hip films to follow up. NO change in mental
status.
Unable to obtain ROS.
Past Medical History:
HTN
Hypothyroidism
HL
Constipation
Cataracts
Depression
Osteoporosis
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION:
Vitals: 98.5 114/30 150/53 70 16 99RA
General: NAD
HEENT: Sclera anicteric, MMM, NAD
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: occasional premature beats, otherwise regular with no
murmurs appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis or edema;
dopplerable pedal pulses L hip with dressing in place
Neuro: moves all extremities, EOMI
DISCHARGE:
Vitals: 98.5 130/46 85 16 98RA
General: NAD
HEENT: Sclera anicteric, MMM, NAD
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: occasional premature beats, otherwise regular with no
murmurs appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis or edema; L hip
with dressing in place
Neuro: moves all extremities, EOMI
Telemetry: premature atrial beats, no episodes of SVT
Pertinent Results:
ADMISSION:
___ 03:41AM BLOOD WBC-9.9 RBC-3.05* Hgb-9.8* Hct-29.6*
MCV-97 MCH-32.3* MCHC-33.3 RDW-13.0 Plt Ct-70*
___ 03:41AM BLOOD Neuts-79.7* Lymphs-13.2* Monos-5.9
Eos-0.9 Baso-0.3
___ 03:41AM BLOOD Plt Ct-70*
___ 03:41AM BLOOD ___ PTT-25.7 ___
___ 03:41AM BLOOD Glucose-162* UreaN-23* Creat-1.2* Na-136
K-4.0 Cl-96 HCO3-28 AnGap-16
___ 03:41AM BLOOD CK(CPK)-144
___ 08:22AM BLOOD cTropnT-<0.01
___ 03:41AM BLOOD cTropnT-<0.01
___ 03:41AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.9
DISCHARGE:
___ 06:27AM BLOOD WBC-9.5 RBC-2.65* Hgb-8.2* Hct-24.4*
MCV-92 MCH-31.0 MCHC-33.7 RDW-15.9* Plt Ct-92*
___ 06:27AM BLOOD Plt Ct-92*
___ 06:27AM BLOOD Glucose-106* UreaN-17 Creat-0.8 Na-131*
K-3.7 Cl-95* HCO3-29 AnGap-11
___ 06:17AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8
CT C SPINE:
IMPRESSION:
1. No evidence of a fracture.
2. Minimal anterolisthesis of C4 on C5 is almost certainly
related to
degenerative disease.
3. Atherosclerosis with severe stenosis of the proximal left
subclavian
artery, not fully assessed.
CT HEAD:
IMPRESSION: Stable appearance of left parietal/occipital
subarachnoid
hemorrhage.
PLAIN FILM HIP:
FINDINGS: Comparison is made to previous study from ___.
Multiple fluoroscopic images of the left hip from the operating
room
demonstrate interval placement of a short intramedullary rod
with proximal pin
and distal interlocking screw. There is improved anatomic
alignment. There
is a minimally displaced lesser trochanter fracture fragment.
There are mild
degenerative changes of the superolateral hip joint. Please
refer to the
operative note for additional details.
Brief Hospital Course:
___, ___ speaking only, w/ HTN, HL, OA, and
hypothyroidism presenting from an OSH for evaluation of left hip
fracture and SAH - now s/p ORIF and being transferred to
medicine service because of SVT at OSH
# femur fracture: s/p ORIF. Pain currently controlled. 8 pt Hct
drop post-op. Appears to be mechanical fall in setting of L leg
weakness (baseline) and dementia. Unlikely to be related to
toxic metabolic insult. Per patient's niece her ___
with getting out of bed on her own is baseline issue. Patient
had 1 fall while in hospital despite bed alarm as she tried to
get out of chair. She should be monitored very closely as she
has tendency to try and get out of bed on her own. She,
furthermore, needs to be seen by orthopedics in 10 days post
discharge.
# Fall: Patient likely had mechanical fall given description by
family and report that patient frequently is stubborn and tries
to get up per her routine. Patient placed on fall precautions,
no evidence of head strike.
# SVT: at OSH, broke with adenosine/dilt. Unclear etiology. No
episodes of SVT on telemetry. On metoprolol without incident.
Likely in setting of catecholamine surge from pain after
fracture.
# Anemia: 8 pt Hct drop post-op, likely ___ procedure rather
than occult blood. s/p 2U PRBC with good reponse, now with
continued minor HCT drop. No hemodynamic compromise, likely
minimal oozing from operation site. She should have follow up
hgb/hematocrit as an outpatient to ensure no further bleeding.
Her discharge HCT is 24.
# SAH: ___ fall - stable per repeat CT scan and Nsurg.
- f/u CT scan head in 1 week (___), if no interval change
with some resorption then can switch DVT prophylaxis to lovenox
30 daily (per neurosurgery)
# Thrombocytopenia: At OSH plt count was 69, ___ years prior was
250. Unlikely to be heparin related so patient restarted on
heparin SubQ. Has been improving throughout her stay.
# Confusion: likely baseline dementia. No other si/sx of toxic
metabolic insult.
INACTIVE ISSUES:
# HTN: switch atenolol to metoprolol; her HCTZ/triamterene were
discontinued as she was normotensive with just metoprolol
# HL: cont statin
# Hypothyroid: cont. levothyroxine
Transitional Issues:
-f/u HCT on ___, if less than or equal to 21, discuss with
rehab physician and consider repeat CT hip to look for occult
bleed
- f/u head CT on ___, if the area of hemorrhage is
improving, please transition Ms. ___ to lovenox at 30mg
daily SC for 3 weeks and d/c sc unfractionated heparin.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Docusate Sodium 100 mg PO DAILY
2. Simvastatin 10 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Calcium Carbonate 500 mg PO Frequency is Unknown
5. Loratadine *NF* 10 mg Oral qday
6. Aspirin 81 mg PO DAILY
7. TraZODone 50 mg PO HS:PRN insomnia
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Senna 1 TAB PO BID:PRN constipation
10. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Senna 1 TAB PO BID:PRN constipation
5. Simvastatin 10 mg PO DAILY
6. TraZODone 50 mg PO HS:PRN insomnia
7. Vitamin D 1000 UNIT PO DAILY
8. Heparin 5000 UNIT SC BID
9. TraMADOL (Ultram) ___ mg PO Q4H:PRN pain
10. Loratadine *NF* 10 mg Oral qday
11. Multivitamins 1 TAB PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp<100
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left intertrochanteric fracture
Discharge Condition:
-
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after having a fall. You underwent
surgery and did well. You had no episodes of fast heart beats
while you were here, which you had before you were transferred.
You remained confused, however this appears to be similar to
your prior confusion at home.
You were found to have a bleed in your brain, which was stable.
You should have a repeat CT scan on ___. If the area of
bleeding is improved, you can switch to a different blood
thinner called Lovenox.
Your blood pressure medication was changed to a medication
called metoprolol. Please take this once per day and
discontinue atenolol.
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- WBAT LLE
-f/u HCT on ___, if less than or equal to 21, discuss with
rehab physician and consider repeat CT hip to look for occult
bleed
- f/u head CT on ___, if the area of hemorrhage is
improving, please transition Ms. ___ to lovenox at 30mg
daily SC for 3 weeks and d/c sc unfractionated heparin.
Followup Instructions:
___
|
10423888-DS-8 | 10,423,888 | 22,432,042 | DS | 8 | 2114-07-17 00:00:00 | 2114-07-21 17:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS and nausea/vomiting
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr ___ is a ___ year old male without significant past
medical history who presents to ___ with nausea, vomiting and
AMS.
Mr ___ was in his USOH until 2d PTA when he developed the
sudden onset of vomiting on Saturaday around ___. He did not
eat anything beforehand. Vomiting intially food products, then
turned bilious. Could not stop. Overnight, patient was moaning
all night and felt as something was stuck in his chest. Spit up
all night adn continued to vomit bilious fluid. Overnight he was
not "talking/acting right" per his girlfriend" and he developed
sweats and chills. He reported to the ___. Abdominal CT
and CXR were normal at that time. He was diagnosed with
gastroenteritis and discharged home with zofran and benadryl.
Patient continued to have worsened nausea at home over the next
severak hours, spitting up and vomiting. Ocassional blood tinged
in the vomitus. He has not had anything to eat since that time.
Last bowel movement and oral feeding was ___ afternoon.
Cannot recall last time he passed gas. No subjective or
objective fevers. No neck stiffness. Possible phonophobia, no
photophobia.
Patient denies any recent travel. No medication changes. No
recent antibiotics. No recent new drug use. No new occupational
exposures or sick contacts. Denies a history of oral or genital
ulcers. Denies present or past IV drug use. No new sexual
contacts.
Patient denies any falls. Denies headache. No fall, headstrike.
Denies vision changes, double vision, blurry vision, ringing in
ears, sinus congestion, cough. No dysphagia, No neck stiffness.
No CP, palpitations. Not short of breath. No abdominal pain. No
diarrhea. No new rashes or lesions. No trauma. Endorses some
lightheadedness.
Denies a history of seizures, sickle cell, or migraines.
ED COURSE
In the ED, initial vital signs were: 10 98.4 90 136/83 16 99% RA
Exam notable for non focal neuro exam and ? epigastric pain
Labs were notable for bland CSF with limdly increased CSF
opening pressure. AST 52.
Patient was given 2mg ativan and zofran
On Transfer Vitals were: 0 98.3 77 127/80 16 98% RA
On the floor patient is confused, unable to provide a full
detailed history.
Past Medical History:
HSV esophagitis diagnosed at ___ E's
H pylori, unclear if treated
Multiple ED visits/admits for nausea/vomiting at ___ E's
PAST SURGICAL HISTORY: Patient endorses having an abdominal
surgery ___ years ago" for "removing a lot of gas" No further
details. Per imaging he has had a cholecystectomy.
Social History:
___
Family History:
Patient unable to provide fully due to confusion, but denies
specifically seizures or migraines
Physical Exam:
ADMISSION PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals: 99.3 125/97 55 18 100/RA
General: Young black male, confused, lying hunched in bed, occas
moves to spit. Occasionally attempts to get out of bed.
HEENT: NC/AT, Eyes anicteric, sclera non-injected. Conjunctivae
pink, No sinus pressure tenderness. Grossly normal oropharynx
with good dentition. MMM.
Fundoscope: Limited to non-dilated exam and patient
non-compliance with fixartion. Able to visualize disks, but
unable to assess disc to cup ratio. Blood vessels appear grossly
normal w/o hemorrhage.
Lymph: No supraclavicular, cervical, or inguinal lymphadenopathy
CV: RRR, nl S1+S2, no S3/S3 no g/r/m. JVD not visualized. 2+
radial and DP pulses b/l.
Lungs: CTAB with normal I:E ration, good air movement b/l. No
w/r/r
Abdomen: soft, nt/nd, near absent bowel sounds. Tympanic to
purcussion. No organomegally. No rebound/guarding. 3 laproscopic
incisions, healed noted on right abdomen.
GU: Normal external genetalia.
Ext: WWP, dry. No c/c/e
Neuro: AAOx1.5 (Thought in ___ at ___, ___ Normal
visual fields, EOMI without nystagmus. Patient with abnormal
impuslse testing on right. Inability to fixate eyes with
abnormal tracking, but not sacchadic. Eyes drooping. ? Ptosis.
___ facial sensation b/l. Facial movements symmetrical and
without droop. Normal smile. Palate elevation and tongue
extension midline. Hearing grossly intact b/l. Equal shoulder
shrug bilaterally. ___ strenght in major flexors/extensors in
shoulders, arms, wrists, hips, knees, and ankles. Sensation
intact to fine touch b/l. Reflexes 2+ in b/l brachicephalic,
achilles, and patellar reflexes. No dysmetria. Rapid had
flapping slowed somewhat. No dysmetria. Romberg negative.
Skin: hyperpigmeneted over right shoulder, > new. abrasion on
right palm. No other rashes lesions.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5 115/64 58 18 100RA
General: well-appearing, conversive gentleman.
HEENT: NCAT, EOMI, MMM
Lungs: CTAB with no w/r/r, breathing comfortably on RA.
CV: normal S1/S2, RRR, no murmurs, rubs, or gallops
Abdomen: soft, not distended, non-tender, no organomegaly, bowel
sounds present
Ext: 2+ peripheral pulses
Neuro: AOx3, CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___ 11:00AM BLOOD WBC-10.8* RBC-5.68 Hgb-15.9 Hct-45.6
MCV-80* MCH-28.0 MCHC-34.9 RDW-13.4 RDWSD-38.4 Plt ___
___ 11:00AM BLOOD Neuts-85.3* Lymphs-9.2* Monos-4.8*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.23* AbsLymp-1.00*
AbsMono-0.52 AbsEos-0.00* AbsBaso-0.02
___ 11:00AM BLOOD ___ PTT-25.4 ___
___ 11:00AM BLOOD Plt ___
___ 11:00AM BLOOD Glucose-118* UreaN-12 Creat-1.0 Na-135
K-5.6* Cl-98 HCO3-23 AnGap-20
___ 11:00AM BLOOD ALT-22 AST-52* AlkPhos-43 TotBili-0.5
___ 11:00AM BLOOD Lipase-25
___ 11:00AM BLOOD cTropnT-<0.01
___ 11:00AM BLOOD Albumin-5.1 Calcium-10.0 Phos-2.1* Mg-1.9
___ 11:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:17AM BLOOD Lactate-2.5* Na-139 K-5.2*.
.
MICRO:
CSF GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
___ 12:10PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
___ ___ 12:10PM CEREBROSPINAL FLUID (CSF) TotProt-12*
Glucose-79
.
DISCHARGE LABS
================
___ 08:00AM BLOOD WBC-7.8 RBC-5.62 Hgb-15.7 Hct-45.6
MCV-81* MCH-27.9 MCHC-34.4 RDW-13.2 RDWSD-38.2 Plt ___
___ 08:00AM BLOOD ___ PTT-29.4 ___
___ 08:00AM BLOOD Glucose-90 UreaN-10 Creat-0.9 Na-135
K-3.9 Cl-97 HCO3-26 AnGap-16
___ 08:00AM BLOOD ALT-19 AST-26 LD(LDH)-215 AlkPhos-42
TotBili-0.6
___ 08:00AM BLOOD Calcium-9.6 Phos-3.2 Mg-1.8
___ 08:00AM BLOOD SED RATE-Test
___ 03:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
STUDIES
ECG ___
Sinus rhythm. Possible left ventricular hypertrophy. Diffuse
non-diagnostic repolarization abnormalities. No previous tracing
available for comparison.
Rate PR QRS QT QTc (___) P QRS T
65 82 420 428 0 61 97
Sinus rhythm. Diffuse non-diagnostic repolarization
abnormalities. Compared to the previous tracing there is no
significant change.
Rate PR QRS QT QTc (___) P QRS T
62 124 88 430 433 44 76 86
___ cxr pa/lateral FINDINGS: Heart size is normal. The
mediastinal and hilar contours are normal. The pulmonary
vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
Clips in the right upper quadrant suggest prior cholecystectomy.
IMPRESSION: No acute cardiopulmonary abnormality.
___ CT HEAD
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
No osseous abnormalities seen. There is mild mucosal thickening
of the left frontal sinus and left anterior ethmoidal air cells.
The remaining paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Mild paranasal sinus disease, as described above.
KUB FINDINGS:
The bowel gas pattern is normal. There are no abnormally dilated
loops of
small or large bowel. There is no evidence of pneumatosis or
pneumoperitoneum. The visualized osseous structures are
unremarkable.Surgical clips project over the right upper
quadrant.
IMPRESSION: No evidence of obstruction.
esphageal barium study/xr ___
The esophagus was not dilated. There was no stricture within
the esophagus.
There was no esophageal mass. The esophageal mucosa appears
normal.
The primary peristaltic wave was normal, with contrast passing
readily into the stomach. The lower esophageal sphincter opened
and closed normally.
There was no gastroesophageal reflux. There was no hiatal
hernia.
No overt abnormality in the stomach or duodenum on limited
evaluation.
IMPRESSION:
There is no esophageal dilatation. Normal esophagram.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
======================
Mr ___ is a ___ year old male with history of herpetic
esophagitis and h. pylori who presents to ___ on ___ with
nausea, vomiting and AMS. Given the broad differential for AMS
in a young otherwise healthy person we conducted a work up for
infectious etiologies with CSF negative for CMV and ESB. HIV
antibodies were also negative. CSF and blood cultures pending.
CNS studies only signficant for elevated opening pressure on LP
(26, nl 15), which is c/w with patient's nausea and vomiting.
Unclear what could cause elevated ICP, but with normal CT,
malignancy, bleed, hydrocephalus are unlikely. Neurology was
consulted and patients mental status ultimately returned to
normal with no specific intervention. Likely toxic metabolic
encephalopathy. Patients nausea and vomiting continued through
the evening of ___ and he received ondansetron and
Prochlorperazine. Additionally he was started on omeprazole for
esophagitis. While inpatient he underwent a barium swallow test
with normal results. He was advised to stop marijuana use as
this episode could represent cyclical vomiting syndrome. He was
discharged home on ___ with a follow up GI appointment.
ACTIVE MEDICAL ISSUES
=====================
# Toxic metabolic encephalopathy. On admission, patient was AOx1
and girlfriend noticed concerning personality changes, as he was
not "talking right." Most likely etiology is altered mental
status in the setting of acute epigastric pain and n/v, which
has since resolved with supportive care. Another possible
etiology is infectious, but LP found no microorganisms. If an
underlying central infection exists, these LP findings are most
consistent with a viral meningitis, such as HSV or enterovirus.
HIV antibody was negative. Intracranial lesions or bleeding that
increase ICP could also alter mental status, although head CT
was negative for acute intracranial process. Tox screen was
negative. Given sudden onset of AMS with vague changes in
personality, this could also be the first manifestation of
epilepsy or pseudoseizure, although neuro exam is unrevealing
and head CT was normal. Endocrine disorders like adrenal
insufficiency could also create changes in mental status,
however AM cortisol was elevated to 31.3. CRP nonspecifically
and midly elevated to 5.7. ESR =2. TSH was normal (0.70).
Finally, psychiatric conditions like borderline personality
disorder or schizophrenia could also be evaluated as an
outpatient. Toxicology was consulted and did not think it was
secondary to a clear toxidrome except perhaps marijuana use.
# NAUSEA/VOMITING:Patient has h/o herpetic esophageal
ulcerations and h. pylori gastritis and has been nauseous and
intermittently vomiting since 2 days before admission. Most
likely ___ esophageal dysfunction. Other etiologies include
cyclical vomiting syndrome due to marijuana usage, or resolving
gastroenteritis. Patient also notably has a a previous abdominal
surgery (which seems to be cholecystectomy). Will need
outpatient EGD.
# EPIGASTRIC PAIN: Patient previously endorsed ___ "cutting"
epigastric pain in the epigastric region. Likely related to
retching in the setting of n/v. No blood visible in emesis and
resolved once n/v resolved. EKG unchanged from ___ with TWI in
precordial leads V2, V3, V4, and V5. Trops x2 and CK-MB were
negative.
TRANSITIONAL ISSUES
====================
- Code status: Full.
- Emergency contact: cell ___, ___ (HCP)
___, sister ___ ___.
- Studies pending on discharge: CSF EBV PCR, fluid culture, and
enterovirus cx, Blood cultures from ___.
- Encouraged to quit marijuana (concern for cyclic vomiting).
- Needs GI follow up given history of HSV esophagitis,
ulcerations of stomach with h. pylori in the past, patient is
not sure if he's been treated. Author strongly counselled
patient in the presence of his father and also when alone to
keep his follow up appointments.
- Consider stopping PPI in ___ weeks if patient's symptoms
improve.
.
[X] Time spent on discharge activities: > 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg one tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
2. Omeprazole 20 mg PO DAILY esophagitis
RX *omeprazole 20 mg one capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea and vomiting possibly due to an infection or marijuana
use.
Toxic metabolic encephalopathy
Diarrhea
Hypophosphatemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you! You were admitted to the
hospital here at ___ on ___ because you could not stop
vomiting. We gave you medications for nausea and did a barium
swallow test, which was normal. We think your nausea, vomiting,
and diarrhea could be related to an infection, or potentially
marijuana use. Another possibility is esophageal or stomach
abnormality, so we think it is especially important that you
follow up with the GI specialists (appointment below) so we can
figure out why this keeps happening and make sure that nothing
else is wrong. They may recommend more studies such as an EGD.
While you were here we were concerned that your throat may have
neen injured from all the vomiting and retching so we added
Omeprazole 20 mg DAILY that we want you to take for at least ___
weeks to protect your esophagus.
We also added Ondansetron 4 mg that you can take every 8 hours
as need for nausea.
Followup Instructions:
___
|
10424312-DS-8 | 10,424,312 | 26,763,486 | DS | 8 | 2111-08-07 00:00:00 | 2111-08-07 13:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p LRYGB ___ had acute abdominal pain yesterday, as
well as nausea and emesis. Last flatus around midnight, last BM
yesterday. Reports some subjective fevers/chills. Got CT scan at
OSH concerning for small bowel obstruction so transferred to
___. Currently reports pain has improved after morphine at
___. Denies current nausea/emesis.
Past Medical History:
PAST MEDICAL HISTORY:
1. Obstructive sleep apnea.
2. Hypertension.
3. Gastroesophageal reflux.
4. Obesity.
5. Depression.
6. Fibromyalgia.
7. Seasonal allergies/allergic rhinitis.
8. Fatty liver.
PAST SURGICAL HISTORY:
1. Cesarean section.
2. Hysterectomy for fibroids.
3. Cervical spine surgery.
4. Bunionectomy.
5. Bilateral axillary gland removal.
Social History:
___
Family History:
Mother with arthritis and hypertension. Father with heart
disease and diabetes.
Physical Exam:
On admission:
VS: 98.4, 92, 121/86, 18, 96% RA
NAD
RRR, no MRG, normal S1, S2
CTA b/l
Abd soft, tender in epigastric area but no rebound, guarding, or
rigidity
no ___ edema
On discharge:
NAD, alert
RRR
Abd soft, minimally tender in epigastric region, no rebounding
guarding, or rigidity
Pertinent Results:
___ 04:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:57AM WBC-9.5 RBC-3.67* HGB-10.9* HCT-33.8* MCV-92
MCH-29.6 MCHC-32.2 RDW-13.9
___ 10:57AM CRP-11.1*
___ 10:57AM ALBUMIN-3.3* CALCIUM-8.1* PHOSPHATE-2.3*
MAGNESIUM-2.1
___ 10:57AM LIPASE-45
___ 10:57AM ALT(SGPT)-25 AST(SGOT)-22 ALK PHOS-68 TOT
BILI-0.3
___ 10:57AM GLUCOSE-87 UREA N-15 CREAT-0.6 SODIUM-139
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-28 ANION GAP-8
___ 01:55AM WBC-11.7* RBC-4.29 HGB-12.9 HCT-39.2 MCV-91
MCH-30.0 MCHC-32.9 RDW-13.4
Brief Hospital Course:
Ms. ___ was admitted to the hospital on ___ after
presenting to the ED with abdominal pain and nausea. Her exam
was notable for mild epigastric tenderness. WBC 11.7 and CT scan
showed proximal dilation of small bowel with decompression of
distal loops. She was intially made NPO, on IVF, and given IV
PPI and bowel rest. KUB on hospital day 1 showed progression of
contrast into the colon. Patient continued to pass flatus and
had BM x 2 on hospital day. Her diet was advanced and patient
was able to tolerate stage III bariatric diet without
difficulty. She remained hemodynamically stable throughout the
hospitalization without and cardiac or pulmonary issues.
On day of discharge, patient was passing flatus. She was able to
ambulate independently, saturating well on room air, with stable
vital signs. She expressed readiness for discharge.
Medications on Admission:
1. Aripiprazole 10 mg PO DAILY
2. Duloxetine 60 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Pregabalin 150 mg PO BID
5. Flonase 50 mcg 1 spray each nostril daily
Discharge Medications:
1. Aripiprazole 10 mg PO DAILY
2. Duloxetine 60 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Pregabalin 150 mg PO BID
5. Flonase 50 mcg 1 spray each nostril daily
Discharge Disposition:
Home
Discharge Diagnosis:
Bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with signs and symptoms of a
bowel obstruction. Upon arrival, you were maintained on bowel
rest, given intravenous fluids and monitored. Your bowel
function has returned and you have been able to eat and drink.
You are now preparing for discharge to home and should follow-up
with Dr. ___ in clinic.
Followup Instructions:
___
|
10424473-DS-8 | 10,424,473 | 23,301,759 | DS | 8 | 2153-06-26 00:00:00 | 2153-06-26 19:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p mechanical fall
Major Surgical or Invasive Procedure:
___: Left chest tube placement
History of Present Illness:
Mr. ___ is a ___ male who presents for evaluation
for ongoing shortness of breath and chest pain after a recent
fall. He reports that he had a mechanical fall from standing on
___, at which time he presented to ___ and was diagnosed with L
___ rib fractures. He was discharged from the ED there, but has
had persistent discomfort and difficulty with deep inspiration
since that time. Last night, he felt a "pop" while turning in
bed
followed by persistent shortness of breath and increased work of
breathing. He re-presented to ___, where CT scan was done
revealing of bilateral atelectasis and a left-sided effusion
concerning for hemothorax. He was transferred to ___ for
further evaluation. At time of our evaluation, he expresses
ongoing left chest discomfort and shortness of breath, with no
other sites of pain. No nausea/vomiting, no fevers/chills.
Past Medical History:
Past Medical History: Gout
Past Surgical History: Nasal surgery
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: 98.4 110 114/84 20 94%NC
GEN: A&Ox3, interactive, appearing in discomfort and slightly
tachypneic
HEENT: Normocephalic atraumatic, PERRLA, EOMI, no facial
deformities/tenderness, oropharynx clear, bilateral nares clear,
bilateral ear canals clear
Neck: Trachea midline, no crepitus
Chest wall: No tenderness to palpation/deformity along right
chest, tender to palpation along left lateral mid-chest wall, no
obvious deformity or overlying ecchymosis,
CV: RRR
PULM: Bibasilar crackles,
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.4, 98, 108/70, 18, 97%ra
Pertinent Results:
___ 08:30PM BLOOD WBC-10.0 RBC-5.21 Hgb-16.5 Hct-48.7
MCV-94 MCH-31.7 MCHC-33.9 RDW-12.8 RDWSD-43.6 Plt ___
___ 08:30PM BLOOD ___ PTT-31.9 ___
___ 08:30PM BLOOD Glucose-108* UreaN-11 Creat-0.8 Na-133
K-4.3 Cl-94* HCO3-25 AnGap-18
Radiology:
___ CXR:
In comparison with the study of ___, there again are low
lung volumes. Left chest tube remains in place and there is no
evidence of pneumothorax.
___ CXR: Generally low lung volumes and moderate bilateral
pleural effusions right greater than left, unchanged. Upper
lungs clear. No pneumothorax.
___ CTA chest: No proximal pulmonary embolism.
2. New left small, borderline moderate left anteromedial
pneumothorax. Interval resolution of left pleural effusion.
4. Extensive bibasilar atelectasis is mildly worsened from prior
exam. 5. Multiple left posterolateral non- and minimally
displaced rib fractures involving ribs 5 through 9.
6. Diffuse hepatic steatosis. Cholelithiasis. Other incidental
findings, as above.
___ echo: The right atrium is moderately dilated. The
ascending aorta is mildly dilated. There is no pericardial
effusion.
Imaging from OSH:
CT Chest ___) - ___ 1700 -
Fractures involving the left lateral ___ through 9th
ribs. Left-sided effusion most likely representing a hemothorax
with left lower lobe atelectasis and consolidation. Lung
contusion is also within the differential.
Brief Hospital Course:
___ s/p mechanical fall on ___ with Left ___ rib fractures,
worsening SOB/WOB overnight, with a symptomatic Left
effusion/hemothorax. The patient was hemodynamically stable. The
ED team placed a left chest tube. The patient was admitted for
close respiratory monitoring with pain control, pulmonary
toilet, and incentive spirometry.
Pain was well controlled. The patient was pulling 1500 on the
incentive spirometer. The chest tube remained to suction and
then waterseal until the output had slowed down. Chest xrays
demonstrated resolution of pneumo/hemothorax. the chest tube was
removed on HD3 and post-pull CXR was stable.
The patient experienced urinary retention and required a Foley
catheter. Flomax was started and once the Foley was removed, the
patient was able to void spontaneously without difficulty.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. Physical therapy evaluated the patient
and he was cleared for discharge home.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs and respiratory exam. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. The patient was
discharged home without services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
___: Allopurinol ___
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Allopurinol ___ mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left ___ rib fractures
Left hemothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after a mechanical fall. You
sustained left sided rib fractures and an injury to your lung
that necessitated a chest tube be placed to drain blood and
fluid from your pleural space. Your chest tube has now been
removed and you are recovering well from your injuries. You are
medically cleared for discharge home to continue your recovery.
Please note the following instructions:
* Your injury caused multiple left rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10424641-DS-16 | 10,424,641 | 20,612,539 | DS | 16 | 2124-04-23 00:00:00 | 2124-04-24 20:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
Back pain and fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w/ COPD and asthma who presents with several
day history of fevers, nausea/vomiting, and myalgias. Patient
reports she began having nausea, vomiting, and diffuse myalgias
on ___ morning when she woke up. Symptoms became worse over
the past few days despite Tylenol. She had fever to 100.7 and
chills. She also reports headache, dizziness, and cloudy urine
over the same time period. She denies dysuria, urinary
frequency, diarrhea, constipation. She has no history or past
UTIs.
Past Medical History:
s/p cholecystectomy
eczema
emphesyma
s/p tubal ligation
Social History:
___
Family History:
Family history of cancer in female relatives, unclear of type.
No history of liver or lung problems.
Physical Exam:
ADMISSION EXAM:
===============
VS - 98.3 121/79 89 18 97 RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, marked ttp in R and L flank
extending around to lateral abdomen, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: alert and interactive, MAE
DISCHARGE EXAM:
===============
VS: 97.9 150/95 76 18 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, nondistended, no abdominal tenderness upon
palpation
Back: CVA tenderness bilaterally, much improved from yesterday.
No longer jumping at light touch
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: AxOx3, ambulating without difficulty, steady gait
GU: no foley, otherwise deferred
Pertinent Results:
ADMISSION LABS:
==============
___ 08:13AM BLOOD WBC-12.9*# RBC-4.74 Hgb-12.4 Hct-38.6
MCV-81* MCH-26.2 MCHC-32.1 RDW-14.0 RDWSD-41.5 Plt ___
___ 08:13AM BLOOD Neuts-88.3* Lymphs-2.6* Monos-8.4
Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.38*# AbsLymp-0.33*
AbsMono-1.08* AbsEos-0.00* AbsBaso-0.02
___ 08:13AM BLOOD Glucose-371* UreaN-16 Creat-0.6 Na-132*
K-3.7 Cl-94* HCO3-24 AnGap-18
___ 08:13AM BLOOD ALT-20 AST-20 AlkPhos-87 TotBili-0.2
___ 08:13AM BLOOD Lipase-9
___ 08:13AM BLOOD Albumin-3.7
___ 05:55AM BLOOD Calcium-7.6* Phos-1.4* Mg-2.2
___ 08:28AM BLOOD Lactate-1.3
INTERIM LABS:
============
___ 05:55AM BLOOD %HbA1c-6.5* eAG-140*
DISCHARGE LABS:
===============
___ 06:41AM BLOOD WBC-5.7 RBC-4.43 Hgb-11.5 Hct-37.1 MCV-84
MCH-26.0 MCHC-31.0* RDW-14.2 RDWSD-43.7 Plt ___
___ 06:41AM BLOOD Glucose-89 UreaN-6 Creat-0.5 Na-140 K-4.1
Cl-104 HCO3-26 AnGap-14
___ 06:41AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.8
MICROBIOLOGY
=============
___ Blood Culture: ESCHERICHIA COLI. FINAL
SENSITIVITIES.
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ Urine Culture: ESCHERICHIA COLI >100,000 CFU/mL
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ Blood Cultures pending
STUDIES:
=======
___ CXR IMPRESSIONS:
No acute cardiopulmonary abnormality. Emphysema.
___ CT Abdomen/Pelvis w/ contrast IMPRESSIONS:
1. Bilateral pyelonephritis. No renal abscess.
2. Gallbladder not visualized. Normal appendix.
3. Colonic diverticulosis.
___ EKG IMPRESSIONS:
Sinus tachycardia. Prominent precordial voltage with ST-T wave
abnormalities suggesting left ventricular hypertrophy with
strain and/or ischemia. Compared to the previous tracing of
___ the rate is now faster. ST-T wave abnormalities are more
prominent. Otherwise, no change. Clinical correlation is
suggested.
Brief Hospital Course:
___ w/ COPD and asthma who presents with several day history of
fevers, chills, nausea/vomiting/myalgias and was found to have
bilateral pyelonephritis on CT. Patient was placed on
ceftriazone empirically and urine cultures came back with E.
coli, sensitive to ceftriaxone and ciprofloxacin. One blood
culture on ___ revealed E coli, also sensitive to
ceftriaxone and ciprofloxacin, likely a translocation from her
pyelonephritis. Her symptoms continued to improve with
antibiotic therapy.
She was constipated but began having bowel movements with a
bowel regimen. She initially had an elevated glucose and was
found to be diabetic (a1c 6.5%). Patient's glucose trended down
as her infection was treated. On day of discharge, patient was
transitioned to PO ciprofloxacin to complete a 14 day antibiotic
course to cover both her pyelonephritis and bacteremia (presumed
first day of negative blood culture ___ while antibiotic
therapy). She will complete antibiotic therapy on ___.
ACUTE ISSUES:
============
# Bilateral E coli Pyelonephritis: Positive UA with leukocytosis
to 12.9, fevers to 103 in ED. Bilateral pyelonephritis seen on
CT A/P w/o evidence of abscess, hydronephrosis. Patient denied
urinary tract symptoms such as dysuria, urinary frequency, blood
in urine. Started on ceftriaxone in the ED. Pain managed with
oxycodone and tapered during hospitalization as clinical status
improved. No history of prior UTIs/drug resistance infections.
Urine cultures positive for E coli, pansensitive, including
ceftriaxone and ciprofloxacin. Patient was transitioned to
ciprofloxacin upon discharge with last doses on ___. Patient's
back pain improved during her hospitalization and was afebrile,
feeling well at discharge.
# Bacteremia, gram negative, suspect Ecoli: One blood culture on
___ revealed E coli, also sensitive to ceftriaxone and
ciprofloxacin, likely a transmigration from her pyelonephritis.
Patient was discharged with ciprofloxacin to complete a 14 total
day course for bacteremia (presumed first day of negative blood
culture ___ while antibiotic therapy).
# Hyperglycemia: 371 glucose on presentation to ED, likely
increased in the setting of infection. Patient denied increased
urinary frequency, increased thirst, or weight loss over the
past couple of months. A1c 6.5%. Patient was informed about her
diagnosis and recommended that she speak with her primary care
physician regarding further diabetes management, likely
dietary/lifestyle modifications at this point. Patient's glucose
trended down as pyelonephritis symptoms resolved, no maintenance
treatment initiated during hospitalization.
# Constipation: patient confirmed that she had not had a bowel
movement in many days. Increased her bowel regimen with adequate
results. Patient was discharged with no bowel regimen.
#Hypokalemia/Hypomagnesemia: repleted, resolved.
CHRONIC ISSUES:
===============
#COPD/asthma: no evidence of acute flare during hospitalization.
Patient was continued on her home regimen, and no changes were
made upon discharge.
# Osteoporosis: made no changes to her home regimen upon
discharge.
TRANSITIONAL ISSUES:
====================
[]Patient will need to follow up with primary care physician
regarding her new diagnosis of diabetes (A1c 6.5%).
[]Patient will need to complete a 14 day antibiotic course with
ciprofloxacin on ___.
[]Patient had a few elevated BP readings. Please follow up on
blood pressure in outpatient setting to determine need for
anti-hypertensive therapy.
CODE: Full Code confirmed
EMERGENCY CONTACT HCP:
Name of health care proxy: ___
___: son
Phone number: ___
NEW MEDICATIONS:
================
-Ciprofloxacin 500mg 1 tab by mouth twice a day (last doses on
___
STOPPED MEDICATIONS:
====================
NONE
CHANGED MEDICATION DOSING TO:
=============================
NONE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QFRI
2. Gabapentin 300 mg PO QHS
3. Montelukast 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
6. Tiotropium Bromide 1 CAP IH DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Calcium Carbonate 500 mg PO BID
9. Vitamin D 1000 UNIT PO DAILY
10. Fexofenadine 180 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
Last day will be ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*21 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Alendronate Sodium 70 mg PO QFRI
4. Calcium Carbonate 500 mg PO BID
5. Fexofenadine 180 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Gabapentin 300 mg PO QHS
8. Montelukast 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
-Bilateral pyelonephritis, E. coli pansensitive
-Bacteremia, Gram negative rods, pansensitive
-Diabetes Mellitus Type 2
SECONDARY DIAGNOSES:
====================
-None
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
-You were concerned about your back pain and fevers
What did you receive in the hospital?
-We tested your blood and urine, and you were found to have a
kidney and blood infection. We began antibiotic therapy, and you
responded appropriately.
-You were constipated which may have contributed to your pain.
We gave you laxatives which resolved your constipation and some
of your pain.
-You had high sugars (glucose) in your blood, and we discovered
you have diabetes. Fortunately, your sugar levels are only
mildly elevated and may be managed initially with behavioral
changes.
What should you do once you leave the hospital?
-You should continue taking your antibiotic, ciprofloxacin,
everyday until ___ (last two doses will be taken on
___.
-You should follow up with your primary care physician as
scheduled below. Please speak with your primary care physician
regarding your new diagnosis of diabetes.
-Make sure you continue to hydrate well, roughly 1.5L of water
everyday. Please drink more water if you happen to exercise.
-We did not make any other changes to your home medication
regimen.
NEW MEDICATIONS:
================
-Ciprofloxacin 500mg 1 tab by mouth twice a day (last doses on
___
STOPPED MEDICATIONS:
====================
NONE
CHANGED MEDICATION DOSING TO:
=============================
NONE
Followup Instructions:
___
|
10424641-DS-17 | 10,424,641 | 20,924,956 | DS | 17 | 2125-06-20 00:00:00 | 2125-06-20 19:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with history of asthma, COPD,
nasal polyps, eczema, and diet-controlled DM who presents with
back pain. On ___ morning, she awoke with a R lower back
pain. It was worse with movement and breathing. She had a friend
massage her back and the pain became much worse. The pain is
sharp and wraps around her flank. Tylenol and ibuprofen led to
incomplete relief of her symptoms. She reports no fevers,
chills,
cough, urinary symptoms, nausea, vomiting or diarrhea.
While in the ED, she developed shortness of breath and dry
cough.
Her pain was worsened with cough. She was given nebulizers with
relief. She was found to have leukocytosis to 17.3 and 81% PMNs,
and CXR with mild RUL opacities and was given ceftriaxone,
azithromycin and prednisone. Flu swab was negative. In the ED,
she also experienced extreme lightheadedness while walking and
therefore, decision to admit to medicine for further management.
Upon arrival to the floor, she reports that her main symptom is
back pain. She reports no trauma, ___ numbness/weakness/tingling,
or bowel/bladder incontinence/retention. She reports shortness
of
breath and dry cough that is very mild. No fevers. She is able
to
walk and lightheadedness has improved.
REVIEW OF SYSTEMS:
Negative except as indicated above
Past Medical History:
-bilateral revision endoscopic sinus surgery on ___
-chronic sinus disease with nasal polyps and poorly controlled
asthma with monthly Nucala SQ injections
-s/p cholecystectomy
-eczema
-emphesyma
-s/p tubal ligation
Social History:
___
Family History:
Family history of cancer in female relatives, unclear of type.
No history of liver or lung problems.
Physical Exam:
ADMISSION PHYSICAL EXAM
=============================
VITALS: 99.6, 129/81 100 18 95% Ra
GENERAL: Alert and interactive. Comfortably lying in bed
HEENT: Normocephalic, atraumatic. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: Tenderness to palpation over L-spine and R paraspinal
muscles. R parasternal muscles are strained. ___ ___ strength
bilaterally.
ABDOMEN: Soft, non-tender.
EXTREMITIES: No clubbing, cyanosis, or edema. WWP
NEUROLOGIC: AAOx3, no gross motor/coordination abnormalities.
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: 97.9 PO 128 / 82 Lying 87 18 93 Ra
GENERAL: Alert and interactive. Comfortably lying in bed
HEENT: Normocephalic, atraumatic. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: Tenderness to palpation over R paraspinal muscles and
tense to palpation of R parasternal muscles. ___ ___ strength
bilaterally.
ABDOMEN: Soft, non-tender.
EXTREMITIES: No clubbing, cyanosis, or edema. WWP
NEUROLOGIC: AAOx3, no gross motor/coordination abnormalities.
Pertinent Results:
ADMISSION LABS:
___ 10:13PM BLOOD WBC-17.3*# RBC-4.90 Hgb-12.6 Hct-39.1
MCV-80* MCH-25.7* MCHC-32.2 RDW-14.6 RDWSD-42.5 Plt ___
___ 10:13PM BLOOD Neuts-81.6* Lymphs-9.6* Monos-7.6
Eos-0.2* Baso-0.2 Im ___ AbsNeut-14.14*# AbsLymp-1.67
AbsMono-1.32* AbsEos-0.03* AbsBaso-0.03
___ 10:13PM BLOOD Plt ___
___ 07:50PM BLOOD Ret Aut-0.9 Abs Ret-0.04
___ 10:13PM BLOOD Glucose-110* UreaN-18 Creat-0.5 Na-140
K-4.5 Cl-98 HCO3-27 AnGap-15
___ 07:50PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8 Iron-19*
___ 07:25AM BLOOD D-Dimer-471
___ 07:50PM BLOOD calTIBC-252* Ferritn-234* TRF-194*
___ 11:15PM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 08:10AM BLOOD WBC-10.1* RBC-4.96 Hgb-13.2 Hct-40.0
MCV-81* MCH-26.6 MCHC-33.0 RDW-14.6 RDWSD-42.4 Plt ___
___ 08:10AM BLOOD Plt ___
___ 08:10AM BLOOD Glucose-138* UreaN-9 Creat-0.4 Na-139
K-4.7 Cl-101 HCO3-24 AnGap-14
___ 08:10AM BLOOD Mg-2.4
___ 07:50PM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8 Iron-19*
MICRO:
__________________________________________________________
___ 1:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 11:10 pm BLOOD CULTURE # 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 11:00 pm BLOOD CULTURE # 1.
Blood Culture, Routine (Pending):
IMAGING:
___: Lumbar spine X ray
5 non-rib-bearing lumbar vertebral bodies are present.
Vertebral
body and
disc heights are preserved. No fracture, subluxation, or
degenerative change
is detected. No suspicious lytic or sclerotic lesion is
identified.
___: CXR
1. Asymmetric indistinct opacities in the right upper lung are
concerning for
developing right upper lobe pneumonia versus interval
development
of scarring.
At least moderate centrilobular emphysema is better assessed on
prior chest
CT.
2. Prominence of the main pulmonary arteries raise the
possibility of
pulmonary hypertension. If indicated, this could be assessed by
nonemergent
echocardiography.
Brief Hospital Course:
___ w/ PMHx COPD/asthma presents with pleuritic pain in her R
back/flank, as well as cough, and SOB.
ACUTE/ACTIVE PROBLEMS:
# Back pain
The patient presented with lower back pain that started on
___. She also describes worsening back pain/side pain when she
takes a deep breath. Her back pain was tender to palpation and
she did not have any evidence of fracture on her X ray.
Therefore, most likely etiology is musculoskeletal strain. We
helped to control her pain with Tylenol 1g q6h, flexeril,
lidocaine patch, and home gabapentin.
# Potential COPD exacerbation
# Eosinophilic asthma
# ?RUL Pneumonia
Labs significant for leukocytosis with neutrophilic predominance
and CXR with evidence of mild RUL opacities. No fevers or
productive cough, but concern for pneumonia. Her symptoms were
very
mild, but given new symptoms, we treated for pneumonia.
Initially on ceftriaxone/azithromycin, but after two doses,
ceftriaxone discontinued. Patient was given three more doses of
azithromycin for discharge for a total course of 5 days of
azithromycin. She recived two doses od 40mg PO prednisone, but
this was discontinued prior to discharge given low concern for
COPD exacerbation as patient without wheezing, prolonged
expiratory phase, or crackles. We continued home ad___ and
___. Budesonide was non formulary so held while
inpatient.
# Orthostatic symptoms
In ED, patient felt markedly dizzy upon standing/walking. This
has improved after transfer to floor. Orthostatic vital signs
negative at time of admission. Therefore, patient likely volume
down/dehydrated. The patient's dizziness improved upon
discharge.
# Microcytic anemia: No acute symptoms of bleeding. We trended
her CBC. Iron studies showed low iron and high ferritin
consistent with anemia of chronic disease.
#patient relations involvement: Patient upset that had to stay
in hallway in ED so patient relations involved. Otherwise,
satisfied with care in the hospital.
CHRONIC/STABLE PROBLEMS:
# osteoporosis - continue home alendronate.
# diet controlled DM - previously on glipizide, but recently
taken off because no longer required.
Transitional Issues:
[ ] consider outpatient colonoscopy for iron deficiency/anemia
of chronic disease if not up to date
[ ] monitor CBC in ___ weeks after pneumonia treatment to see if
leukocytosis improving
[ ] continue azithromycin for five day total course to end ___
[ ] follow up dizziness for resolution
# Health care proxy: ___, son, ___
# Code: full, presumed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. Alendronate Sodium 70 mg PO QFRI
3. Fexofenadine 180 mg PO DAILY
4. Gabapentin 300 mg PO QHS
5. Montelukast 10 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral BID
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Nucala (mepolizumab) 100 mg subcutaneous Other
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. Cyclobenzaprine 10 mg PO TID:PRN back spasm pain
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth up to three times
daily Disp #*21 Tablet Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % apply 1 patch nightly Disp #*7 Patch
Refills:*0
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
6. Alendronate Sodium 70 mg PO QFRI
7. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY
8. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral BID
9. Fexofenadine 180 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Gabapentin 300 mg PO QHS
12. Montelukast 10 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Nucala (mepolizumab) 100 mg subcutaneous Other
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Community Acquired pneumonia
Lumbar paraspinal muscle strain
Secondary Diagnosis:
Chronic Obstructive Pulmonary Disease
Eosinophilic asthma
Osteoporosis
Diet controlled diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I ADMITTED?
-You were admitted because you were having back pain, dizziness,
a cough, and shortness of breath
WHAT WAS DONE WHILE I WAS HERE?
-We gave you antibiotics
-We gave you steroids
-We took an X ray of your back which did not show any fractures
WHAT SHOULD I DO NOW?
-You should take your medications as instructed
-You should go to your doctor's appointments as below
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
10425441-DS-5 | 10,425,441 | 27,095,193 | DS | 5 | 2160-05-18 00:00:00 | 2160-05-19 12:34:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
___ Endoscopy
___ Capsule Endoscopy
___ Colonoscopy
History of Present Illness:
Mr. ___ is a ___ year old M w/ hx of CAD w/ on DAPT, hx of
NSTEMI
in ___ (at ___, thought embolic given ectatic arteries, no
history
of PCI), type II DM, HTN, and HLD presenting with dark stools,
chest pain, and a syncopal episode.
He was recently admitted on ___ for cardiac catheterization
after having chest pain at home. Patient had been on ASA/Plavix
and warfarin for a prior NSTEMI thought to be embolic in origin.
The cath at that time was noted to have ectatic coronaries and
was kept on DAPT and warfarin. Since his cath, he has been
having
exertional chest pressure and dyspnea and states he has to stop
and rest frequently to catch his breath. Yesterday, he noticed
he
was having dark red stools that looked 'bloody' and has had two
bloody stools in total (last this AM). This morning he also had
an episode of syncope while walking to the bathroom where he
lost
consciousness for several seconds to minutes. He presented to
his
PCP and was noted to have a hgb drop from 14 to 9 so was
referred
to the ED.
In the ED, patient had no further melena and complaint of
exertional left chest pain that he states has been going on
since
his cath.
Initial Vitals:
T 97.7 HR 89 BP 104/70 RR 20 SpO2 100% RA
Exam:
Head: NC/AT
Eyes: sclera anicteric
Oropharynx: clear
Lungs: clear
Cor: RRR S1 S2 no mrg
Abd: soft, nontender
Rectal: stool melenic, grossly heme pos
Ext: cath site - R radial artery clean and dry
no edema
R knee with small abrasion
___ pulses intact
Labs:
9.0
11.4>------< 229
43.9
140 | 104 | 27
---------------
4.8 | 19 | 1.2
Imaging:
CXR:
Slight interval increase in hazy opacity in the left
retrocardiac
lung. Findings likely represent atelectasis however pneumonia
cannot be completely excluded in the proper clinical setting.
CT C-spine
No acute fracture or traumatic malalignment of the cervical
spine
CT head
No acute intracranial process
GI was consulted and are planning for EGD in the morning.
Cardiology was consulted who said he can get aspirin, but would
hold Plavix and warfarin.
Interventions:
He has received 1 unit pRBCs, IV pantoprazole.
VS Prior to Transfer:
T 98.1 HR 79 BP 96/71 RR 18 SpO2 100% RA
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
NSTEMI ___ ___, ectatic arteries with likely embolus to OM2,
no
intervention)
Type 2 DM not on insulin
Prior tobacco use
Hypertension
Hyperlipidemia
Cholecystectomy
Rotator cuff injury
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: afebrile, HR 99 BP 110/71 SpO2 100% RA
GEN: Pleasant, comfortable, no acute distress
HEENT: supple, no JVD
CV: Normal S1, S2, no murmurs
RESP: CTAB
GI: Normal BS, No TTP
MSK: Warm, no edema
SKIN: warm, no rashes
NEURO: alert and oriented x3. ___ strength in all extremities,
sensation grossly intact
DISCHARGE PHYSICAL EXAM
=======================
Vitals T 98.7 BP 123 / 71 HR 105 RR 18 O2 Sat 97 RA
GEN: Pleasant, comfortable, lying in bed in no acute distress
HEENT: supple, no JVD
CV: Normal S1, S2, no murmurs
RESP: CTAB
GI: Normal BS, No TTP
MSK: Warm, no edema
SKIN: warm, no rashes
NEURO: alert and oriented x3. Grossly non-focal
Pertinent Results:
Admission Labs:
===============
___ 04:49PM BLOOD WBC-11.4* RBC-3.11* Hgb-9.0* Hct-28.4*
MCV-91 MCH-28.9 MCHC-31.7* RDW-14.3 RDWSD-47.2* Plt ___
___ 10:54PM BLOOD WBC-10.0 RBC-3.26* Hgb-9.7* Hct-29.4*
MCV-90 MCH-29.8 MCHC-33.0 RDW-14.4 RDWSD-47.0* Plt ___
___ 03:48AM BLOOD WBC-9.8 RBC-2.95* Hgb-8.7* Hct-26.2*
MCV-89 MCH-29.5 MCHC-33.2 RDW-14.5 RDWSD-46.5* Plt ___
___ 07:03AM BLOOD WBC-9.7 RBC-2.81* Hgb-8.3* Hct-25.0*
MCV-89 MCH-29.5 MCHC-33.2 RDW-14.5 RDWSD-47.0* Plt ___
___ 12:04PM BLOOD WBC-8.9 RBC-2.54* Hgb-7.5* Hct-22.9*
MCV-90 MCH-29.5 MCHC-32.8 RDW-14.4 RDWSD-46.7* Plt ___
___ 07:26PM BLOOD WBC-8.3 RBC-2.87* Hgb-8.8* Hct-25.6*
MCV-89 MCH-30.7 MCHC-34.4 RDW-14.4 RDWSD-45.1 Plt ___
___ 11:55PM BLOOD WBC-8.1 RBC-2.93* Hgb-8.7* Hct-26.0*
MCV-89 MCH-29.7 MCHC-33.5 RDW-14.1 RDWSD-45.9 Plt ___
___ 04:49PM BLOOD ___ PTT-34.7 ___
___ 04:49PM BLOOD Glucose-135* UreaN-60* Creat-1.5* Na-140
K-4.2 Cl-105 HCO3-21* AnGap-14
___ 03:48AM BLOOD Glucose-134* UreaN-43* Creat-1.1 Na-140
K-4.0 Cl-106 HCO3-23 AnGap-11
___ 04:49PM BLOOD cTropnT-<0.01
IMAGING:
========
___ CT C-SPINE W/O CONTRAST
No acute fracture or traumatic malalignment of the cervical
spine
___ CT HEAD W/O CONTRAST
No acute intracranial process
___ EGD
NOrmal mucosa in whole esophagus, erythema in the antrum
compatible with mild gastritis, normal mucosa in whole examined
duodenum, stomach otherwise normal
___ COLONOSCOPY
Mild diverticulosis of the ascending colon, internal
hemorrhoids, otherwise normal colonoscopy without evidence of
old blood or active bleeding. No lg lesions identified but prep
inadequate for screening colonoscopy.
___ CAPSULE ENDOSCOPY
Preliminary review shows no evidence of bleed in small bowel. No
AVMs identified.
DISCHARGE LABS:
===============
___ 01:28PM BLOOD WBC-6.3 RBC-3.06* Hgb-9.1* Hct-28.2*
MCV-92 MCH-29.7 MCHC-32.3 RDW-14.3 RDWSD-47.8* Plt ___
___ 01:28PM BLOOD Glucose-126* UreaN-11 Creat-1.0 Na-141
K-4.2 Cl-106 HCO3-26 AnGap-9*
___ 08:05AM BLOOD ALT-31 AST-44* LD(LDH)-237 AlkPhos-54
TotBili-0.8
___ 01:28PM BLOOD Calcium-9.2 Phos-1.8* Mg-1.7
Brief Hospital Course:
This is ___ year old man with history of CAD on triple therapy
(ASA, Plavix and warfarin), DMII, HTN and HLD who presented with
melena with hgb drop from 14 to 9, syncope and chest pain days
after repeat cardiac catheterization showing microvascular
disease and no discrete culprit lesion s/p admission to ICU for
melena, now hemodynamically stable without melena or bleeding
with endoscopy, capsule endoscopy, and colonoscopy without signs
of active bleeding.
# GI bleed
Presented with one day of melena with significant hgb drop from
14
to 9 with hypotension and syncope. Rec'd 1U PRBC in the ED. No
further melena noted since presentation to ED and H&H has
stabilized since ___ around 9. Had an EGD, capsule endoscopy and
colonoscopy without signs of
bleeding stigmata (final report for capsule endoscopy still
pending but review with GI doctor noted no bleeding and he was
safe for discharge. The GI physician ___ call the patient with
final results). Per Cards recs, held warfarin (no bridge) until
cscope, then restarted with instruction to hold if any bleeding
recurs. Plavix also held during hospitalization, and we did not
discontinue this on discharge. His outpatient cardiologist Dr.
___ was notified via email. He was given PO PPI but this was
discontinued since no GI bleed was identified. Currently
normotensive and asymptomatic and hgb has been stable. His
discharge Hgb was 9.1.
# Ectatic coronaries
# CAD
# Hx of NSTEMI (suspected emboli to OM1)
# Chest pain
Presented with chest pain on ___ and had cardiac cath with
ectatic coronaries w/o flow limiting CAD. Patient was maintained
on DAPT for microvascular disease and warfarin given history of
embolic NSTEMI. Had chest pain on admission with ST depressions
and TWI in lateral leads in ED. Trops on several trends were
negative. Felt that chest pain and dyspnea likely demand from
relative anemia and hypovolemia. Continued to deny CP or SOB
currently. Continued his aspirin, held Plavix and warfarin.
Restarted warfarin prior to discharge and stopped his plavix,
notified cardiologist Dr. ___.
# ___ - resolved
Admission Cr 1.5.
Likely prerenal in setting of GI bleeding and poor PO intake
over
last several days. S/p 1L IVF and 1U PRBC in ED. Cr now 1.1 with
improving BUN. Discharge Cr 1.0
#Hypernatremia - resolved
Sodium increased to 148, likely hypovolemic given losses. Given
1L IVF ___. Discharge Na 141.
CHRONIC ISSUES
===============
# HTN
- Held metop and lisinopril-HCTZ, restarted on discharge
# HLD
- Rosuvastatin 40mg QPM
# T2DM
- Held metformin, given ISS in hospital, restarted on discharge
# Back pain
- Cont gabapentin QHS PRN back pain
TRANSITIONAL ISSUES
===================
- Please follow-up with primary care physician ___ 2 weeks
-- Please obtain repeat CBC at follow-up visit to ensure H&H is
stable
- He may benefit from closer follow-up with cardiologist Dr.
___ that his Plavix was stopped.
NEW MEDICATIONS
NONE
STOPPED MEDICATIONS
Plavix
CHANGED MEDICATIONS
NONE
# CODE: Full
# CONTACT: ___
Relationship: wife
Phone number: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Nicotine Polacrilex 2 mg PO Q6H:PRN for nicotine craving
4. Gabapentin 100 mg PO PRN FOR BACKPAIN AT NIGHT backpain
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
6. Vitamin D ___ UNIT PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Rosuvastatin Calcium 40 mg PO QPM
9. Warfarin 2.5 mg PO 3X/WEEK (___)
10. Warfarin 5 mg PO 4X/WEEK (___)
11. lisinopril-hydrochlorothiazide ___ mg oral DAILY
12. MetFORMIN (Glucophage) 1000 mg PO DAILY
13. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Gabapentin 100 mg PO PRN FOR BACKPAIN AT NIGHT backpain
4. lisinopril-hydrochlorothiazide ___ mg oral DAILY
5. MetFORMIN (Glucophage) 1000 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Nicotine Polacrilex 2 mg PO Q6H:PRN for nicotine craving
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Rosuvastatin Calcium 40 mg PO QPM
10. Vitamin D ___ UNIT PO DAILY
11. Warfarin 2.5 mg PO 3X/WEEK (___)
12. Warfarin 5 mg PO 4X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
GI bleed
Secondary diagnosis:
CAD on triple therapy- stopped Plavix on discharge
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had dark red
stools that looked bloody, low blood pressure, and loss of
consciousness.
- In addition, you had chest pain with exertion as well as
shortness of breath causing you to have to stop and rest
frequently.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We monitored your blood counts (hemoglobin) in the hospital
because they had dropped because of the bleeding and continued
to monitor them until they became stable. You got two units of
blood.
- You received a colonoscopy to evaluate for bleeding in your
lower gastrointestinal tract and an endoscopy and then capsule
endoscopy to look for bleeding in your upper and middle
gastrointestinal tract which did not show any of active
bleeding.
- We monitored your stool for blood and ensured that you were no
longer having bloody stools.
- You tolerated a regular diet prior to discharge.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your appointments as listed below.
--- We recommend that you see your PCP within the next week. We
have included her contact information below.
--- We also reached out to your cardiologist Dr. ___. She may
call you to see you sooner and may also have some
recommendations for you. We updated her on your hospital course.
--- Please stop your Plavix.
- If you hear back from Dr. ___ and she tells you
that you do not have any bleeding in your capsule study based on
her FINAL review, then take your warfarin on ___ and continue
taking it daily (as you have been doing).
- If you notice ANY bleeding at all or feel dizzy or
lightheaded, it is important that you come back immediately (and
stop warfarin)
We wish you the ___!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10425664-DS-11 | 10,425,664 | 26,314,879 | DS | 11 | 2110-06-26 00:00:00 | 2110-06-26 12:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hand ring finger infected cyst
Major Surgical or Invasive Procedure:
___ - Incision and debridement of infected mucous cyst, Dr.
___
History of Present Illness:
___ RHD with R ring finger swelling and pain x6 days. Past
history of recurrent cyst formation over distal dorsal R ring
fingertip. Patient reports expressing mucus fluid drainage on
several previous occasions, but no previous history of
infection.
Seen in hand clinic today by Dr. ___, referred to ED
for
assessment, I&D, admission for abx.
Patient denies fever/chills, n/v, or constitutional symptoms. No
paresthesias, minimal pain with ROM, but limited due to
swelling.
Tetanus UTD.
Past Medical History:
1. HTN
2. R ring finger previous PIPJ surgery ___
3. L hip arthroplasty
4. L4-5 discectomy
Social History:
___
Family History:
unremarkable
Physical Exam:
Exam on discharge:
AVSS, NAD
Right hand ring finger with dressing, c/d/i
NV intact distally
Pertinent Results:
___ 02:20PM WBC-5.6 RBC-4.37* HGB-13.2* HCT-38.7* MCV-89
MCH-30.3 MCHC-34.2 RDW-13.5
Brief Hospital Course:
Patient is an ___ admitted for right hand ring finger infected
mucous cyst.
The patient was started on IV antibiotics and was taken to the
OR on ___ for irrigation and debridement of his cyst. He
tolerated the procedure well with no blood loss or
complications.
The patient was discharged home on the day of surgery with oral
antibiotics and pain medications.
He will follow-up in 1 week with ___, PA.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Keflex
3. Bactrim
4. Oxycodone- acetaminophen
Discharge Disposition:
Home
Discharge Diagnosis:
Right ring finger infected mucous cyst.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You may continue your activities as tolerated. You should
refrain from heavy activity with the affected extremity.
Keep you dressing clean and on until follow-up appointment in 1
week.
Take your antibiotics as prescribed on the prescriptions.
You should continue your current Keflex prescription, and take
Bactrim in addition to this.
Take your pain medications as needed. (Percocet)
Followup Instructions:
___
|
10425845-DS-4 | 10,425,845 | 21,284,404 | DS | 4 | 2164-12-17 00:00:00 | 2164-12-23 13:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o dementia, aortic stenosis on plavix, and hypertension
who sustained a fall at her nursing home. The patient was taking
a shower with the help of an aide when she fell face forward
while attempting to pick up a bar of soap. She struck her face
and per the aide who witnessed her fall did not have any loss of
conciousness or change in mental status after the fall. She did
have signs of facial trauma and was taken to ___ for
evaluation. There, her workup showed a left sided sub-dural
hematoma, left posterior intra-parenchimal hemorrhage, and
interpeduncular subarachnoid hemorrhage. She was neurologically
at her baseline of dementia oriented to self only and was having
a laceration on her lip sutured when she began vomiting what
appeared to be old blood. She then had a decline in her
respiratory status and was intubated for airway protection. She
was then transferred to ___ for further management. Upon
arrival she was intubated, sedated, and had visible diffuse
facial ecchymosis and a lip laceration.
Past Medical History:
HTN, aortic stenosis, dementia, hypothyroid
PSH: hemmorhoidectomy
Social History:
___
Family History:
___
Physical Exam:
Upon admission,
HR: 72 Resp: 18 O(2)Sat: 100 Normal
Constitutional: Sedated
HEENT: Large contusion to brow line, periorbital ecchymosis,
pupils are 3mm b/l are reactive to light 7.5 ETT, 20 @ lip.
c-collar in place. Lip laceration
sutured.
Chest: Equal b/l breath sounds.
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds
Abdominal: Nondistended, Soft
Extr/Back: Multiple areas of ecchymosis over LUE.
Skin: Warm and dry
Neuro: intubated
On discharge,
VS: 98.8 79 157/93 18 98% (2L NC)
Constitutional: well-appearing, in no acute distress
HEENT: Diffuse bruises on face and scalp
Cardiopulmonary: RRR, normal S1 and S2, systolic aortic murmur,
bilateral base crackles. In no respiratory distress
Abdomen: Soft, non-tender, non-distended
Neurologic: AAOx1, grossly intact
Pertinent Results:
___ 01:30PM WBC-9.2 RBC-3.45* HGB-11.0* HCT-35.0*
MCV-101* MCH-31.9 MCHC-31.5 RDW-12.8
___ 01:30PM NEUTS-81.4* LYMPHS-7.9* MONOS-10.1 EOS-0.3
BASOS-0.3
___ 01:30PM PLT COUNT-156
___ 01:30PM CALCIUM-6.9* PHOSPHATE-2.1* MAGNESIUM-1.8
___ 01:30PM GLUCOSE-121* UREA N-20 CREAT-0.6 SODIUM-142
POTASSIUM-4.0 CHLORIDE-112* TOTAL CO2-19* ANION GAP-15
___ 04:06PM O2 SAT-97
___ 07:40PM PLT COUNT-160
___ 07:40PM WBC-13.0* RBC-3.34* HGB-10.9* HCT-32.6*
MCV-98 MCH-32.7* MCHC-33.4 RDW-12.8
___ 07:40PM GLUCOSE-126* UREA N-20 CREAT-0.5 SODIUM-141
POTASSIUM-3.0* CHLORIDE-109* TOTAL CO2-22 ANION GAP-13
___ 07:45PM TYPE-ART PO2-154* PCO2-38 PH-7.40 TOTAL
CO2-24 BASE XS-0
Brief Hospital Course:
Mrs. ___ was admitted to our institution after being
transferred from an outside hospital where she was brought in by
ambulance after sustaining mechanical fall face forward while
showering. Reportedly, patient was intubated at OSH for airway
protection after an episode of bloody emesis. Upon arrival she
was sedated and had visible diffuse facial ecchymosis and a lip
laceration. Repeat imaging studies showed interval increase in
prepontine and interpeduncular subarachnoid hemorrhage tracking
inferiorly, and confirmed the presence of a small
intraventricular and a left subdural hemorrhage. Given findings,
the neurosurgery team was consulted and recommended conservative
management and monitoring for further interval changes. Patient
was thus admitted to the ___ for further care.
Regarding her facial injuries, the ___ team was consulted to
assess the lip laceration and dental injuries. Evaluation and
repair was initially difficult given the presence of an
endotracheal tube. A repeat head CT scan showed no interval
changes 24 hours later. Upon stabilization of her respiratory
status, patient was extubated on hospitalization day #1. A
tertiary survey revealed no further injuries. At this point,
___ was able to repair the lip laceration. There was avulsion
of tooth #9, as well as mild mobility in teeth #8 and 10. At
this point, decision was made not to place a dental splint given
time elapsed from injury and questioned benefit from it. She was
advised to stay on a full-liquid diet and follow-up with outside
dentist once medically stable for definitive care.
On hospitalization day #2 patient was started on ciprofloxacin
for a urinary tract infection (confirmed by urinalysis and
cultures positive for Klebsiella). Home medications were
restarted upon diet tolerance, except for Plavix, to be held for
one week post-injuries per neurosurgery recommendations. Given
favorable response, she was transferred to the floor on
hospitalization day #4. Foley catheter was then removed and
patient had several episodes of incontinence. Anticipating
discharge, physical therapy was consulted and determined need
for extensive ___ rehab. Case management was
involved in the rehab selection process.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. She was tolerating a full-liquids diet,
and pain was well controlled. The patient's family members and
aide received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
1. Simvastatin 10 mg PO DAILY
2. Furosemide 10 mg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. Aripiprazole 2 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Ciprofloxacin HCl 250 mg PO Q12H
7. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Simvastatin 10 mg PO DAILY
2. Furosemide 10 mg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. Aripiprazole 2 mg PO DAILY
5. Acetaminophen 1000 mg PO Q8H
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Ciprofloxacin HCl 250 mg PO Q12H
9. Losartan Potassium 50 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
If your doctor allows, non steriodal ___ drugs are
very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
Please abstain from taking Plavix until you follow up with
Neurosurgery in clinic in 4 weeks.
Please take a full liquid (non-chew) diet for the next two weeks
or until you follow up with a dentist for definitive dental care
regarding your tooth injury.
Followup Instructions:
___
|
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